Prefix                           Last Name                                    First Name                              MI                     Sex                   Social Security #         
  Select One Mr. Mrs. Ms.                        Male Female   

                                                    Date of Birth                  Phone Number                            Alternate Phone Number 
                                                  

      Home Address                     Number of People to Shelter 

   Mailing Address           Number of People to Transport 

                            City       Zip Code                    Subdivision

Name of Apartment Complex or Mobile Home Park                       Apartment or Lot Number   

            Nearest Major Intersection or Cross Street   
 

                        Do you live in a Mobile Home?    No yes                                                   Do you have a Pet?  No yes

                Do you live in and Evacuation Zone?    No yes                                              Pet Shelter Arranged?   No yes

             Will you be accompanied by a Caregiver?    No yes                                     Do you own a Wheelchair?  No yes

                                       Caregiver            

                     Relative or Friend (Local)            

                 Relative or Friend (National)           

                                     Physician              

                  Home Health Care Agency           

                               Oxygen Provider            

          
                                Bedridden?              Can you be moved in a Wheelchair?         Wheelchair Bound?                Walker/Cane?
                                 No yes                     Wheelchair Not Needed No yes                       No yes                     Neither Walker Cane

                                                                                                              --------------- click any that are applicable -------------
  Oxygen? No yes      Hours used per day?      Liter flow?      Portable Tank     Nebulizer     Respirator

    Diabetic (Insulin) No yes      Diabetic (Non-Insulin) No yes      Visually Impaired No yes      Hearing Impaired No yes

            Wound Care No yes                         Dialysis No yes         Cardiac History No yes         Blood Pressure No yes    

                                                                                                                                         If on Life Support - List equipment being used
                    Allergies No yes              Life Suport Equip No yes        

 

Additional Medical Condition / Health Need:

 

                                                                 Highlighted areas must be filled out
  
                Transportation Requested   None School Bus Wheelchair Van Ambulance                   Requested Shelter Type   None Public Special Needs Nursing Home Hospital

I understand the limitation on services and level of care available. I grant permission to medical providers, transportation
agencies and others as necessary to provide care and disclose any information necessary to respond to my needs.
I understand that registration does not guarantee assignment to the requested shelter type, all assignments will be made
on the basis of medical need and available space at the time of evacuation. This registration is voluntary and I hereby
request registration in the Special Needs Program.

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           Completed By:           Agency:

     Registrant's Signature               Date   
                                     By entering my name I agree for this to act as my signature                                        mm/dd/yyyy

      
        Your Email Address               Are you a person with Special Needs   No yes