SN Application
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EMERGENCY
EVACUATION REGISTRY FOR PEOPLE WITH SPECIAL NEEDS This form should only be completed by or on behalf of people
who are physically unable to reach shelter, bus pickup points or care for
themselves and do not have family, friends or care givers who can adequately
assist them during an evacuation situation.
Completion of this form is voluntary. COMPLETE AND RETURN TO:
EMERGENCY MANAGEMENT
c/o HENRY GORDON
FOR
INFORMATION CALL:
(864) 638-4200
A. GENERAL INFORMATION SOCIAL SECURITY NO.: _______________________________________ 1.
NAME: ____________________________________________
(Last)
(First)
(MI) ADDRESS:
______________________________ APT. #_____ CITY: Mailing Address
(If different from above) ___________________________________________________ TELEPHONE:
____________________ MALE: __ FEMALE: __ DATE OF BIRTH; __________ HEIGHT: _____ WEIGHT: ____ 2.
AGENCY: __________________________________________ CASEWORKER
(Primary): _____________________________
(Other): ______________________________ TELEPHONE
(Primary): _______________________________
(Other): ________________________________ 3.
IF I MUST LEAVE MY HOME I WILL:
___ Stay with a relative/friend in . ___________________________________________________ ___________________________________________________ Name of Family
Member or Agency: ___________________________________________________ TELEPHONE:
Home _______________________________
Work _______________________________ 5. Primary Caregiver/Companion who will accompany you in time of emergency: NAME:
____________________________________________ TELEPHONE:
Home _______________________________
Work _______________________________ Relationship:
________________________________________ 6. Nearest Relative/Friend who will not be accompanying you: NAME:
____________________________________________ TELEPHONE:
Home _______________________________
Work _______________________________ Relationship:
________________________________________ B. COMMENTS: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ C. MEDICAL INFORMATION SPECIAL
MEDICAL NEEDS (e.g., SPECIAL CARE INSTRUCTIONS) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ ALLERGIES:
______________________________________________________________________________________________ SPECIAL
DIETS:
__________________________________________________________________________________________ VISUALLY
IMPAIRED: _____________________________
TDD PHONE EQUIPMENT: _______________________________ HEARING
IMPAIRED: _____________________________
SPEAKS ENGLISH: YES ____________ NO
_________________ SIGN
LANGUAGE ONLY: __________________________
IF NO – SPECIFY: ______________________________________ MUST YOU USE?:
WHEEL CHAIR _______________ CRUTCHES _____________ WALKER/CANE
________________ ARE YOU BEDRIDDEN?: YES
___________________ NO
___________________ DO YOU USE?: TYPE
PORTABLE
HOURS/DAY
SPECIAL INSTRUCTIONS DIALYSIS
_________
__________ ______________________________________________ OXYGEN
_________
__________ ______________________________________________ RESPIRATOR
_________
__________ ______________________________________________ IV’S
WITH PUMP
_________
__________ ______________________________________________ OTHER
_________________
_________ __________ THIS SECTION TO BE COMPLETED BY PERSONAL PHYSICIAN, NURSE, OR CASE MANAGER IF 24 HOUR SKILLED NURSING OR EMERGENCY SERVICES IS NECESSARY. (PLEASE TYPE) PRIMARY DOCTOR/CASEWORKER: ________________________________________
TELEPHONE: _______________________ SPECIAL INSTRUCTIONS:
____________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ AUTHORIZATIONS (PLEASE READ CAREFULLY) I CERTIFY THAT ALL THE INFORMATION I
PROVIDED IS CORRECT. I UNDERSTAND
THAT I AM RESPONSIBLE FOR ALL EXPENSES ASSOCIATED WITH MEDICAL EVACUATION, CARE
AND SHELTER AT A HOSPITAL OR OTHER FACILITY.
I ALSO UNDERSTAND DATE: ________________________________
SIGNATURE: _______________________________________________________ IF CASEWORKER OR OTHER COMPLETED THIS FORM, ALSO SIGN:
Relationship FOR AGENCY USE ONLY: |