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HURRICANES

Hurricane Evacuation Transportation Registration

Do you need assistance with transportation to evacuate?
First Name:
Last Name:
Street Address:
Apartment #:
City:
ZIP Code
Phone Number:
Gender:
 
In case of emergency ...
Emergency First Name:
Emergency Last Name:
Emergency Relationship:
Emergency Phone Number:
 
If others are evacuating with you, how many?
.  
Do you have a pet?
If YES, how many pets?
Do you have carriers for every pet?
.  
Do you have medical special needs?
For the above ... One who needs assistance during evacuation and sheltering because of physical or mental handicaps OR one who requires a level of care and resources beyond the basic first aid level of care that is available in shelters for the general population.
Do you or anyone evacuating with you use oxygen?
 
What category describes your special needs?
Level 1: A person dependent on others or in need of others for routine care (eating, walking, toileting, etc.). Child under 18 without adult supervision, etc.
Level 2: A person who is blind, hearing impaired, deaf/blind, or has an amputation.
  -- Do you use a service animal?
Level 3: A person needing assistance with medical care administration, monitoring by a nurse, dependent on equipment, assistance with medications, mental health disorders.
Level 4: A person outside an institutional facility care setting who require extensive medical oversight (i.e., IV chemotherapy, ventilator, peritoneal dialysis, hemodialysis, life support equipment, hospital bed and total care, or is morbidly obese)
Level 5: A person in institutional setting such as hospitals, long-term care/assisted living facilities, or state schools.
-- If you selected Level 3, 4, or 5, do you use a wheelchair?
 
.  
Are you confined to a bed?
Do you require power
for medical equipment?