Special Needs/ Evacuation Assistance form Once this registration form is processed, your local municipality will contact you. - Step 1 of 5 20% Name* First Last Date or Birth* Date Format: MM slash DD slash YYYY mm/dd/yyyyGender*MaleFemaleAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Mobile Phone* Do you require Transportion Assistance?YesNoWhat is your Living Situation?*I live aloneI live with relativesType of Home*Single Family ResidenceMobile HomeApt/CondoWhat is the name of the complex you live in?* Which one of these services do you have?* Caretaker Home Health Nurse What is the name of your Caretaker?* First Last What is your Caretakers Phone Number?*What is the name of your Home Health Nurse?* First Last What is your Home Health Nurses Phone Number* Special Needs ( CHECK ALL THAT APPLY ) * Kidney Disease Dialysis Diabetes High Blood Pressure Heart Disease Stroke Speech Impaired Cancer Asthma Emphysema COPD Breathing Treatment Oxygen Ventilator (cannot breathe on your own) Mental Health Impaired (Schizophrenia, Obsessive Compulsive, Violent Behavior) Memory Impaired Sight Impaired Service Dog Hearing Impaired Walker/Cane Wheelchair User Bedridden Only Geri Chair Incontinence Feeding Tube Allergies Electrical Dependent None Emergency Contact* First Last Emergency Contact Phone Number
