Emergency Management
Pinellas County Evacuation Assistance - Special Needs Registration Form
Last First
Street# Street Name
I Require Transportation Assistance: Yes No
Living Situation:    Relative
    

--Team ID
 

Special Needs (Check all that apply) Questions? Call Health Department at 727-538-7277 ext. 7916
-unable to stand Oxygen Concentrator
Diabetes Feeding tube
-Oral Medication Other Special Needs
-Schizophrenia
-Obsessive Comp. -Wear Adult Diapers
-Violent Behavior
Memory impaired Mandatory SpNS
Dialysis, Oxygen, Breathing Treatment, Feeding Tube (syringe feedings or for medications only)
Bring all supplies to SpNS
Sight impaired
-Wears Glasses
-Blind
Service dog
None
   
  --  
Emergency Contacts
Name
Name Relationship

Name Relationship Phone
Doctor's name Relationship Phone
Form Completed by Relationship Phone
Official use only:
Transport to: General Shelter   Special Needs Shelter  Other
Type of Transport: Own Vehicle   Van/Bus   Wheelchair Only   Ambulance
Fire Dist: Grid: Level: Shelter Name:
Comments:

By filling out this form I give my authorization for the medical information contained herein to be released to the county health department, emergency management, local fire districts and receiving facilities for the purpose of evaluating my needs and providing emergency transportation and sheltering. Records relating to registration of disabled citizens are exempt for the provisions of F.S. 119.07(1), Public Records Law. The information contained here will be kept confidential.

E-mail addresses are public records under Florida law and are not exempt from public-records requirements. If you do not want your e-mail address to be subject to being released pursuant to a public-records request, do not send electronic mail to this entity. Instead contact this office at 727-464-3800, or fax to: 727-464-4024, or in writing, via the United States Postal Service to

Office of Emergency Management
Public Safety Complex
10750 Ulmerton Rd.
Building 1, Suite 267
Largo, FL 33778

PDF version
Special Needs/Evacuation Assistance Program