Fillable Special Needs Form BENSALEM EMERGENCY MANAGEMENT NEEDS YOUR HELP

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Special Needs Form BENSALEM EMERGENCY MANAGEMENT NEEDS YOUR HELP

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Special Needs Information
As Bensalem Emergency Management continues to train and
prepare for a variety of incidents that our municipality might be faced with,
we are asking for your help.
This form allows us to identify the residents within our Township that
have special needs and require special assistance during times of crisis.
These needs could include individuals with disabilities, diabetes, mental
health issues; or people that are on oxygen or need special care when
being evacuated; or need to have contact access during snow
emergencies.
In order to be better prepared and make sure that we can identify and
contact our special needs residents during a crisis, we need to have any
resident with special needs fill out the information sheet and return it either
in person or via mail to the Bensalem Municipal Building, c/o Fire Rescue
Department, 2400 Byberry Road, Bensalem PA 19020.
All information provided will be held in the strictest confidence.
EMERGENCY MANAGEMENT
SPECIAL NEEDS INFORMATION
Name of Person:
DOB:
Location of Residence:
Home Phone:
Emergency Contact:
Cell Phone:
Nature of Problem:
Needs Oxygen
Needs Dialysis
Mentally Challenged
Deaf (May not be able to hear smoke alarm)
Needs Assistance Evacuating Home
Other Help Needed (Please Explain)
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Special Needs Form BENSALEM EMERGENCY MANAGEMENT NEEDS YOUR HELP

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Completed 11 July 2020

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