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Special Needs Registry Form

  1. Applicant Information
  2. This should be the phone number you answer most often. This information may be used to contact you in an emergency and may be included in an automated alert notification system.
  3. Do you have a TTY/TDD*
  4. If yes, is the Primary Phone Number for your TTY/TDD?
  5. Do you have a service animal?*
  6. Condition/Mobility
  7. Do you need any assistance hearing people?*
  8. Do you have a visual impairment?*
  9. Do you need assistance communicating with people?*
  10. Do you have problems getting around without help?*
  11. Do you have a: (Check all that apply)
  12. Emergency Contact
  13. Relationship to Applicant*
  14. Is the person completing this form the applicant?*
  15. Acknowledgement
    The information that I have provided is true and accurate to the best of my knowledge, and I am submitting this application voluntarily. I understand that my contact information may be provided to local, county, state, and federal agencies for the purposes of emergency planning and emergency response. I understand that my acceptance to the Special Needs Registry does not guarantee assistance in evacuation or sheltering. I authorize emergency personnel to enter my home, if necessary, to assist me and ensure my safety and welfare during an emergency.
  16. Or
  17. Leave This Blank:

  18. This field is not part of the form submission.