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Special Needs Registry
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Special Needs Registry Form.
Please fill out the following information. Should you have any questions please feel free to call (856) 935-7510 ext. 8311 or 8316. All information will be kept strictly private and confidential.
Today's Date
Full Name:*
Date of Birth:
Home Address:
Apt. No.:
City:
Zip Code:
Telephone:
TDD:
E-mail:
Height
Weight Over 300lbs?Yes   No  
Emergency Contact Name:
Emergency Contact E-mail:
Emergency Contact Address:
Emergency Contact City:
Emergency Contact State:
Emergency Contact Zip Code:
Emergency Contact Phone:
Relationship:
Other Info:
Evacuation Information (Check all that apply)Sight Impaired
  Hearing Impaired
  Speech Impaired
  Physically Impaired
  Completely Bedridden
  Mentally/Memory Impaired
  Dementia/Alzheimer's
  Dialysis
  Requires constant skilled nursing skills
  Other  
Other Disability:
Does not:Have access to a motor vehicle
  Have a radio or television
  Have a telephone
  Speak English (Explain below)  
Primary Language:
Has difficulty walking and requires:Manual Wheelchair
  Motorized Wheelchair
  Walker/Cane
  Attendant to assist in ambulating  
Requires medical equipment that is not easily transportable(check all that apply)Oxygen concentrator or cylinder
  Ventilator
  Suction Machine
  Other (explain below)  
Other Equipment:
Are all of the conditions resulting in the need for evacuation assistance temporary?Yes   No  
Do you have a service animal?Yes   No  
Do you have pets?Yes   No  
Do you have medications that must be taken with you if evacuated?Yes   No  
Do you have a 24 hour caretaker?Yes   No  
Name of Caretaker:
Caretaker Phone:
Do you require evacuation assistance 24/7?Yes   No  
If No, what time do you need evacuation assistance?
Do you have any allergies?Yes   No  
Allergy Type:
Physician Name:
Physician Phone:
Pharmacist Name:
Pharmacist Phone:
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