Pinellas County Evacuation Assistance - Special Needs Registration

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Special Needs/Evacuation Assistance Program

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:		CARE TAKER HOSPICE TEAM HOME HEALTH , Phone
DO YOU HAVE A PET? Yes No	Arrangements for pet completed – Call 582-2600 for assistance details Yes No

SPECIAL NEED SHELTER ONLY (CHECK ALL THAT APPLY) For assistance call the Department of Health at 727-820-4155
Kidney disease	Emphysema	Breathing treatment	Feeding tube
Diabetes/insulin depend	Memory impaired	Walker/cane	Ventilator
High blood pressure	Mental health impaired	Wheelchair bound	Electric dependent, Why?
Heart disease	Sight impaired	Bedridden	Other
Dialysis	Service dog	Incontinence	None
Stroke	Speech impaired	Oxygen (lpm )
Cancer	Hearing impaired	Geri chair

Emergency Contacts
NAME		PHONE
NAME		PHONE
Prearranged:	Hospital Nursing Home ALF
	Name		Phone
	Doctor's name		Phone

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 by telephone or in writing, via the United States Postal Service.

e-mail

Date

Official use only:

Fire Dist:

Grid:

Evac Level:

Select the Send Form button below, or mail completed form to:
Office of Emergency Management, 400 South Fort Harrison Avenue, Suite 111 Clearwater, FL 33756
or fax to: 727-464-4024. For more information please call 727-464-3800. Rev. 02/06