Caregiver's name and phone number who will be
accompanying you at the shelter?
Special Needs Registry Form
Name:
Physical Address:
Mailing Address:
Phone Number:
Date of Birth:
Physician’s Name:
Phone:
Home Health Care Provider:
Phone:
Where do you plan to stay during an evacuation?
no home Will you be alone? yes
with friends/family
emergency shelter
Ca
n you get to an evacuation shelter? yes
no
If
no, check(one) for the appropriate transportation
needed
:
standard vehicle (car, van)
wheelchair equipped
ambulance
Do you have a care giver?
no
Please check all special needs you may
have:
legally blind
deaf
terminally ill
contagious disease
bedridden
ambulatory with assistance (walker, cane,
wheelchair, etc.)
dialysis (3 or more times per week)
IV fluids or medication
insulin dependent (need assistance)
feeding tube
catheter (other than urinary)
severe respiratory illness
oxygen tank number of hours/day
do you have a portable tank yes no
severe mental handicap
severe mental illness
end-stage Alzheimer's
chronic incontinence
advanced senile dementia
require complex dressing changes
unstable Gran Mai seizures
moderate to severe symptomatic HIV/AIDS
medically dependent on electricity
equipment:
access to a generator
type
of
diet
Additional Information
*If you do require a caregiver, your caregiver MUST
accompany you to the facility as assistance is not provided by
the facility.
Emergency Contact
Name:
Have you made arrangements for pets as they are not allowed in
evacuation shelters?_____________________________________
I certify that the above information is correct to the best of my
knowledge and I have read this brochure in its entirety. Services
provided during the specified disaster will be provided at no charge. If
you continue to utilize services after you have been cleared to return
home, you will be responsible for those costs. Signed
Date
