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Special Medical Needs Registry

  1. Sex
  2. Living Situation
  3. Your care giver must accompany you to shelter. Please provide their info below:
  4. If possible, please make arrangements for your pets as they may not be allowed at shelters.
  5. Transportation Needs
  6. Can you get to an Evacuation Shelter?
  7. If no, please check the appropriate transportation needed
  8. Medically dependent on electricity for?
  9. Oxygen dependent
  10. If yes, oxygen type:
  11. Frequency of use
  12. Medical Contact Info
  13. Acknowledgement:
    The information that I have provided is true and accurate to the best of my knowledge, and I am submitting this application voluntarily. I understand that my contact information may be provided to local, county, state, and federal agencies for the purposes of emergency planning and emergency response. I understand that my acceptance to the Special Needs Registry does not guarantee assistance in evacuation or sheltering. I authorize emergency personnel to enter my home, if necessary, to assist me and ensure my safety and welfare during an emergency.
  14. OR
  15. Leave This Blank:

  16. This field is not part of the form submission.