Transportation Assisstance Registry

Do you need assistance with transportation to evacuate?

What is your primary spoken language?

First Name:

Last Name:

Street Address:

Apartment #:

City:

ZIP Code

Phone Number:

Email Address (lower case only)

Gender:

Emergency Contact

First Name:

Last Name:

Relationship:

Phone Number:

If others are evacuating with you, how many?

Do you have a pet?

If yes, how many?

Do you have carriers for every pet?

Do you have medical special needs? If NO please select Not Applicable to the remaining questions.

(Definition of Special Need: 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.)

What category describes your special needs?

Do you require supplemental oxygen?

Do you use a service animal?

Do you use a mobility device? (Wheelchair, scooter, etc...)

Are you confined to a bed?

Do you require electricity for life support equipment?

Do you require power for recharging medical equipment?