Pinellas County Florida Evacuation Assistance

Pinellas County Evacuation Assistance - Special Needs Registration Form

Last	First	DOB	M/F
Street#	Street Name		Apt/Lot
City	ZIP	Phone
I Require Transportation Assistance: Yes No
Living Situation: Alone Relative Other
Single Family Residence Mobile Home APT/Condo, Complex Name:
Caretaker: Name -- Phone Hospice --Team ID -- Phone Home Health -- -- Phone
Do You Have a Pet? Yes No Arrangements for pet completed Yes No (Call Animal Services 727-582-2600 for assistance details)

Special Needs (Check all that apply) Questions? Call Health Department at 727-824-6932
Kidney disease	Asthma	Walker/Cane	CPAP/BiPAP
Dialysis	Emphysema	Wheelchair User	Elec. Wheelchair/Scooter
-Center	COPD	-may stand with help	Nebulizer (for breathing)
-Days a Week	Breathing trtmt	-unable to stand	Oxygen Concentrator
Diabetes	Oxygen	Bedridden Only	Feeding tube
-Insulin dependent	Ventilator	Geri Chair	Other
-Oral Medication	Mental impaired	Incontinence	Other Special Needs
High blood pressure	-Schizophrenia	-Occasionally
Heart disease	-Obsessive Comp.	-Wear Adult Diapers
Stroke	-Violent Behavior	Feeding Tube
-No problems	-Other	-Unable to Swallow*
-Needs Assistance	Memory impaired	-24 hr feedings*	Mandatory SpNS Dialysis, Oxygen, Breathing Treatment, Feeding Tube (syringe feedings or for medications only) Bring all supplies to SpNS
Speech impaired	Sight impaired	-for Meds only
Cancer	-Wears Glasses	-Syringe Feeding only
-Year	-Blind	**24 Hour Tube Feedings or unable to swallow needs to go to a hospital or nursing home
-On Chemo Now	Service dog
-On Radiation Now	Hearing impaired		None
	-Hard of Hearing	Allergies
	-Deaf	--

Emergency Contacts
Name	Relationship	Phone
Name	Relationship	Phone
Prearranged:	Hospital Nursing Home ALF Other
Name	Relationship	Phone
Doctor's name	Relationship	Phone
Form Completed by	Relationship	Phone

e-mail

Date

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