Special Needs Application

Would you need special help during an emergency evacuation?

Special Needs Application
Date Submitted: Date Submitted: / MM / DD YYYY
If you have a disability that requires special help during an emergency evacuation, please fill out and return this card as soon as possible. State and local authorities will keep this information confidential.

Please Note - Even if you have sent in a Special Needs Card in the past, a new card should be sent in each year to keep our records current.
Name: Name: * First Middle Last
Email Address: *

Confirm Email Address: *
Address: Address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
County: *
Phone: Phone: * - ### - ### ####
I am completing this card for someone else: *

I am completing this card for someone else: Yes No
Your Name: Your Name: * First Middle Last
Your Phone: Your Phone: * - ### - ### ####
Please check off each box that applies to you: *

Please check off each box that applies to you: I do not have transportation available to leave the area during an emergency evacuation. I use a cane or walker, but can ride in a van, bus or car. I am in a wheelchair and would need a wheelchair van. I would need to ride in an ambulance. I am deaf or hard of hearing. I am visually/sight impaired and require help. I require and use a service animal. I have specialized medical equipment and require special transportation(explain below). Other(Please Explain) Other(Please Explain)
Why Do You Require Special Transportation? *
I Would Like Someone Contacted During An Emergency Evacuation: *

I Would Like Someone Contacted During An Emergency Evacuation: Yes No
Contact Name: Contact Name: * First Middle Last
Ways To Contact: *

Ways To Contact: Home Phone Work Phone Other Phone
Home Phone: Home Phone: * - ### - ### ####
Work Phone: Work Phone: * - ### - ### ####
Other Phone: Other Phone: * - ### - ### ####

Special Needs Application

Special Needs Application

Special Needs Application

If you have a disability that requires special help during an emergency evacuation, please fill out and return this card as soon as possible. State and local authorities will keep this information confidential.