Sex:    Male Female

DOB       Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Date Form completed      Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2007 2008 2009 2010

Type of Residence: Private Special Needs Public Housing

Facility/Residence/Community Name

Street Address *Not a PO Box

Apartment Building Name and Number

Floor Level

Municipality/City

Phone Number Cell Phone

E-mail Address

How well do you understand the English language?
Well Not Well Not Well at all

Primary Language Spoken

If Special Needs, Special Needs Residence Type:

Assisted Living Retirement Community Senior Housing
Group Home Residential Health Care Facility Other

How many people including yourself are in your household? Live Alone 1 Other Person 2 Other Persons 3 Other Persons more than 3 people

Are you responsible for minor children living with you? Yes No
         If Yes, how many?

Emergency Contact Information

First Name Middle Initial
Last Name

Street Address *Not a PO Box

City State Zip Code

Phone Number Cell Phone

Fax Number

E-mail Address

The following information will further help us prepare for your evacuation

Do you have pets living with you? Yes No

Do you have a service animal? Yes No

Weight Range Less than 300 lbs 300 lbs or over

Are You Bed Bound Yes No

You walk with the assistance of:
No Assistance Another Person Cane Crutches Walker
Service Animal Other

Do you use a wheelchair or scooter? Yes No
Type: Manual wheelchair Motorized wheelchair Scooter

Sight Impaired? No impairment Need Glasses Blind

Hearing impaired? No impairment Hearing Aid Deaf

Check all items that apply:

Use Oxygen Use Respirator Cognitive Impairment
Alzheimer dementia Developmental Disability Mental Health Condition

Evacuation Transportation Requirement

Do you require transportation? Yes No
If Yes:

The following information will be helpful for your possible stay at an Emergency Shelter

Do you have:

Personal Emergency Kit? Yes No
Medication List? Yes No
File/Vial of Life? Yes No
Food Allergies? Yes No
      If yes, specify:
Other Allergies? Yes No
      If yes, specify
Dialysis required? Yes No
      If yes, specify how often

This form was filled out by:
Self Family Member Other (Name)

I am submitting this form voluntarily, for the use by emergency personnel, in the event that I should require assistance during an emergency.

By checking this box, I am signing this document and verifying the information above is accurate. Note, this box must be checked in order for the information to be submitted.

Enter the code shown below letters are case sensitive

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