PINELLAS COUNTY EVACUATION ASSISTANCE/SPECIAL NEEDS REGISTRATION
Registration for: Special Needs Shelter Transport Assistance Both
Once this registration form is processed, you will be contacted by your local Fire Department
LAST: __________________________________ FIRST: _____________________________ Male Female
STREET ADDRESS:________________________________________________________ APT#__________ LOT#:___________
CITY:________________________________________ ZIP:_________________________ PHONE:___________________________
DATE OF BIRTH: _____/_____/_____ EMAIL: _____________________ LIVING SITUATION: ALONE RELATIVE OTHER
SINGLE FAMILY RESIDENCE MOBILE HOME APT/CONDO COMPLEX/PARK NAME:__________________________
DO YOU HAVE A PET: YES NO Arrangements for pets completed. If not, call 727-582-2600 for assistance.
NUMBER OF DOGS ______ Approx. Weight______ NUMBER OF CATS_____ NUMBER OF BIRDS_____ TOTAL ANIMALS_____
PRIMARY LANGUAGE SPOKEN __________________________
RESIDENCY: PERMANENT TEMPORARY If Temporary, START DATE_____________ END DATE____________
What assistance do you require? CHECK ALL THAT APPLY
Standing
Transferring to a Bed
Dressing
Toileting
Ostomy
Catheter
List other assistance required
__________________________
__________________________
__________________________
MOBILITY ASSESSMENT
I am ambulatory- able to move
on own? Yes
No
I am bedridden
I use a wheelchair
Able to stand with
assistance
Unable to stand with
assistance
I weigh over 400 Pounds
Yes No
If Yes – approx. weight ____
ELECTRIC DEPENDENT
CPAP/BPAP
Oxygen: _______LPM
____ No. of hours daily
Ventilator
Concentrator
Nebulizer
Feeding Pump
Suction Pump
Cardiac Monitor
Medicine requires
refrigeration? If yes, what?
_____________________
Dialysis
COGNITIVE ASSESSMENT
Alzheimer’s/ Dementia
Psychiatric Disorder
Obsessive Compulsive
Depression
Self-injurious or danger to
others
List Other Cognitive or
Special Need Issues
______________________
______________________
______________________
______________________
SPECIAL CARE
Feeding Tube
Unable to swallow
24 hour feedings
For medications only
Syringe feedings only
Client must bring all supplies
needed for care to the shelter.
Diabetes
Insulin Dependent
Oral Medication (pills)
Do you have a DO NOT
RESUSCITATE Order?
Yes (Please bring D.N.R.)
No
Questions? Call Health
Department – 727-824-6932
Have you PREARRANGED to go to a:
Hospital Nursing Home ALF Other: ____________________________________
Name of PREARRANGED facility where you will be evacuating to ___________________________________________
ADDRESS _______________________________________________________ PHONE____________________________
DOCTOR’S NAME ______________________________________________________ PHONE____________________________
Do you receive HOSPICE: NAME________________________ TEAM ID__________PHONE ___________________________
Do you receive HOME HEALTH: NAME ____________________________________PHONE ___________________________
Emergency Contact
NAME ____________________________________RELATIONSHIP________________ PHONE_____________________________
I certify that at least one caretaker/companion will accompany me YES HOW MANY _____________
NAME____________________________________RELATIONSHIP________________PHONE_______________________________
Is caregiver registered in Special Needs database? YES NO
Mail completed form to: Pinellas County Emergency Management, 10750 Ulmerton Rd. Building 1, Suite 267, Largo, FL 33778 or fax to 727-
464-4024. For more information, please call 727-464-3800. Rev. 2017
Form completed by (PRINT NEATLY): ____________________________ Relationship: _____________ Phone #________________
If not completed by the applicant, do you currently possess a Power of Attorney for the individual? YES NO
By signing this form I give my authorization for the medical information contained herein to be released to the county health department,
emergency management, local fire districts and receiving facilities for the purpose of evaluating my needs and providing emergency
transportation and sheltering. Records relating to registration of disabled citizens are exempt for the provisions of F.S. 119.07(1), Public
Records Law. The information contained here will be kept confidential.
____________________________________________________________________ ___________________
