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2. First Name
3. Last Name
5. Adsress
7. City
8. State
9. Zip
11. Primary Phone Number
12. Alternate Phone Number
14. DOB:
15. Age
16. Primary Language
17. Sex

    1. Male
    2. Female
19. Living Situation

    1. Alone
    2. Relative
    3. Caregiver
    4. Other
20. If you answered other, please explain:
22. Your care giver must accompany you to shelter. Please provide their info below:
24. Caregiver Name
25. Relationship to caregiver
27. Care Giver Phone Number
29. Emergency Contact Name (if other than caregiver)
30. Emergency Contact Phone Number
32. If possible, please make arrangements for your pets as they may not be allowed at shelters.
34. Transportation Needs
36. Can you get to an Evacuation Shelter?

    1. Yes
    2. No
37. If no, please check the appropriate transportation needed

    1. Car
    2. Wheelchair Van
    3. Ambulance
    4. Other
39. If other, please explain:
41. Medically dependent on electricity for?

    1. O2 Concentrator
    2. Feeding Pump
    3. Suctions
    4. Other
42. If other, please explain:
44. Oxygen dependent

    1. Yes
    2. No
45. If yes, oxygen type:

    1. Liquid
    2. Bottle
    3. Room Air
46. Frequency of use

    1. 24 hour
    2. Intermittent
    3. Only Overnight
    4. CPAP
48. Medical Needs/Conditions:
50. Know Food or Drug Allergies:
52. Other Medical Equipment: please specify
54. Medical Contact Info
56. Primary Doctor
57. Phone:
59. Home Health Provider
60. Phone:
62. Home Medical Equipment Provider
63. Phone:
65. Pharmacy Name
66. Phone:
68. 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.
70. Applicant Name
72. OR
74. Person authorized to submit this application:
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field