Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Special Needs Survey

  1. Personal information for individual with need
  2. Is primary phone TTY/TTD?
  3. Weight over 300 pounds
  4. Personal Information for Emergency Contact
  5. Evacuation Information
  6. Individual is/has:
  7. Does not:
  8. Has difficulty walking and requires:
  9. Requires medical equipment that is not easily transportable:
  10. 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.)
  11. Condition(s) are temporary
  12. Additional Information
  13. Does the person in need have a service animal?
    (i.e: seeing eye dog)
  14. Does the person have a 24 hr. caregiver?
  15. Does the person have pets?
  16. Does the person require evacuation assistance 24/7?
  17. Does the person have medications that must be taken with them if evacuated?
  18. Is this person a seasonal resident?
  19. Leave This Blank:

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