Please bring all medications with you to the shelter. Please list medications below:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SUPPORT AGENCIES (Section E)
Healthcare Agency: ________________________________ Phone: ________________________
Contact Person: ______________________________ Phone: ________________________
Doctor/Physician: __________________________________ Phone: ________________________
Contact Person: ______________________________ Phone: ________________________
Insurance Provider: _________________________________ Phone:_________________________
Contact Person: ______________________________ Phone: ________________________
Medical Equipment Provider: _________________________ Phone: ________________________
Contact Person: ______________________________ Phone: ________________________
Other Healthcare Agency: ____________________________ Phone: ________________________
Contact Person: ______________________________ Phone: ________________________
TRANSPORTATION AND SPECIAL NEEDS REGISTRY AGREEMENT (Section F)
I understand that a Special Needs Shelter does not provide beds, cots, or lifts, and that I should plan
to bring my own, and that assistance will only be provided for the duration of the evacuation and in
the event I am not able to return to my home that I will be responsible for any additional
transportation/hospital expenses. I understand Emergency Management will determine if any
emergency evacuation assistance will be provided. I understand that power is not guaranteed, due to
unforeseen power fluctuations or power failures.
Upon order or recommendation to evacuate, if I have requested transportation, I will receive advance
notice, by phone, of the date and time to expect to be picked up for transport to a shelter. If I decline
transportation when a transporter arrives, I understand that I may not have another opportunity to
obtain this service.
I grant permission to medical providers, transportation agencies, and others as necessary to provide
care and disclose any information necessary to respond to my needs. I certify that this information is
correct to the best of my knowledge. My caregiver (if one is assigned) will be present during my stay
at the shelter.
_______________________________________________ _________________________
Applicant Signature Date
If the person completing this form is not the patient, please state:
Name: _________________________________ Phone: __________________________
Relationship/Agency: ________________________________________________
