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2. Personal information for individual with need
4. First Name*
5. MI
6. Email
8. Last Name*
9. Suffix
10. Primary Phone*
12. Address*
13. Is primary phone TTY/TTD?

    1. Yes
15. Address Line 2
16. Secondary Phone
18. City*
19. State*
    -- Select One --AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
20. Zip Code
21. Date of Birth
    Date of Birth
23. Height-Feet
24. Height-Inches
25. Weight over 300 pounds

    1. Yes
26. Gender
    -- Select One --MaleFemale
28. Municipality
    -- Select One --Bellefonte BoroughBenner TownshipBoggs TownshipBurnside TownshipCentre Hall BoroughCollege TownshipCurtin TownshipFerguson TownshipGregg TownshipHaines TownshipHalfmoon TownshipHarris TownshipHoward BoroughHoward TownshipHuston TownshipLiberty TownshipMarion TownshipMiles TownshipMilesburg BoroughMillheim BoroughPatton TownshipPenn TownshipPhilipsburg BoroughPort Matilda BoroughPotter TownshipRush TownshipSnow Shoe BoroughSnow Shoe TownshipSpring TownshipTaylor TownshipUnion TownshipUnionville BoroughWalker TownshipWorth Township
29. Latitude
30. Longitude
34. Personal Information for Emergency Contact
36. First Name
37. MI
38. Email
40. Last Name
41. Suffix
42. Primary Phone
44. Address
45. Secondary Phone
47. Adddress Line 2
48. Relationship
    -- Select One --RelativeFriend
52. Evacuation Information
54. Individual is/has:

    1. Sight impaired
    2. Hearing impaired
    3. Speech impaired
    4. Physically impaired
    5. Completely bedridden
    6. Mentally/memory impaired
    7. Dementia/Alzheimers
    8. Dialysis
    9. Requires constant skilled nursing care
    10. Other reason for needing assistance
55. Does not:

    1. Have access to a motor vehicle
    2. Have a radio or television
    3. Have a telephone
    4. Speak English
57. Has difficulty walking and requires:

    1. Manual wheelchair
    2. Motorized wheelchair
    3. Walker/cane
    4. Attendant to assist in ambulating
58. Requires medical equipment that is not easily transportable:

    1. Oxygen concentrator or cylinder
    2. Ventilator
    3. Suction machine
    4. Other equipment
59. Please specify other equipment:
63. Duration of Need:
    Are all of the conditions resulting in the need for evacuation assistance temporary? (Example: Bedridden due to pregnancy difficulties but expected to be fully recovered after the baby is deliverd.)
65. Condition(s) are temporary

    1. Yes
    2. No, the condition(s) are expected to be permanent
66. If yes, please provide an estimated date when the condition will be resolved
    If yes, please provide an estimated date when the condition will be resolved
70. Additional Information
72. Does the person in need have a service animal?

    (i.e: seeing eye dog)

    1. Yes
    2. No
73. Does the person have a 24 hr. caregiver?

    1. Yes
    2. No
75. Does the person have pets?

    1. Yes
    2. No
76. Does the person require evacuation assistance 24/7?

    1. Yes
    2. No
78. Does the person have medications that must be taken with them if evacuated?

    1. Yes
    2. No
79. Evacuation assistance is needed from/to:
    Evacuation assistance is needed from/to: Start Time

    —

    Evacuation assistance is needed from/to: End Time
81. Is this person a seasonal resident?

    1. Yes
    2. No
82. If seasonal, this person is a resident from/to:
    If seasonal, this person is a resident from/to: Start Date

    —

    If seasonal, this person is a resident from/to: End Date
84. Please enter any additional information that may be useful for our emergency personnel to evacuate this person:
Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit Submit and Print

* indicates a required field