Special Needs Registration Form

Special Needs Registration Form

The Special Needs Registration form can be downloaded here (Adobe PDF format),
printed, filled out and mailed to the Emergency Operations Center, or you can
fill it out online and submit it. If you choose to mail it in, please mail it to:

Baker County Emergency Operations Center
1190 W Macclenny Ave
P.O. Box 958
Macclenny, FL 32063

Department of Emergency Management
SPECIAL NEEDS REGISTRATION FORM

This program is designed for those who have special physical and/or medical needs and may require
government evacuation and/or shelter assistance in the event of an emergency. Please complete all
fields in their entirety and click the 'Send' button. Your email program will open with a new outgoing
message - click the send button in your email program and your request will be submitted.

In the event of an actual emergency, response agencies will attempt to provide the necessary assistance
but because of significantly increased demands on government resources this cannot always be assured.
To best guarantee personal safety, individuals should take the necessary advance precautions and follow
planning guidance issued by government response agencies.

Should you require special/ambulance transportation and/or hospital facilities you must make those
arrangements yourself.

The management of nursing, convalescent, retirement and other group facilities are responsible for
the evacuation and sheltering of their own residents.

PERSONAL ENROLLMENT DATA

First Name:	Middle Name:	Last Name:


Date of Birth	Gender	Phone Number
	Male Female

Street Address	City	Zip


Residence Type	Rural	Living Situation
	Yes No

EMERGENCY CONTACTS

Name (Local):	Relationship:	Phone Number:


Name (Non-Local):	Relationship:	Phone Number:


Person completing this form (if different from above):


Address/Company		Phone Number


Home Health or Assisting Agency		Phone Number

MEDICAL CARE INFORMATION

Special Medical Needs (check all that apply):
Medical Dependence on Electricity	Memory Impaired	Anxiety/Depression
Mental Health Impaired	Respirator Dependent	Dialysis Dependent
Insulin Dependent	Speech Impaired	Emergency Alert Monitors
Walker/Cane	Bedridden	Mobility Impaired
Wheelchair Bound	Incontinence	Special Dietary Needs
Sight Impaired	Hearing Impaired	Oxygen Dependent
Other:
Medical Problems:

Primary Doctor	Telephone


Pharmacy	Telephone


Health Insurance Company	Telephone


Allergies:


Medications:

ASSISTANCE REQUIRED

Transportation to a Shelter:		Assistance in a Shelter:
Yes No		Yes No
Check needs:		Check needs:
Bus Car Wheelchair Van Ambulance (see note above)		Personal Care Feeding Taking Medicine Other - please specify:

Pets (check all that apply):
Cat Dog Guide Dog Other - please specify:

Special Needs Registration Form

Department of Emergency Management SPECIAL NEEDS REGISTRATION FORM

Department of Emergency Management
SPECIAL NEEDS REGISTRATION FORM