Special Needs List Form - English

1S INFORMATION WILL BE KEPT CONFIDENTI |
1/ this person will need assistance in the event of an emergency or evacuation: PLEASE PRINT.
name date
stroot address:
lity state Zip code
[Phone number call)
home(__) work(__) “TOOMTY(_)
you are a parttime resident (Le., summer only) please list the months you are living at this address: From:
To:
Please mark an “X" in each box that applies.
" Telecommanication Deve forte DealText Telephone
This isa now survey, or one that hasnt been updated in years. []
Need assistance for evacuation forthe following reasons:
@ o use a wheelchair and
a o Hearing impaired and need Life Support Device
‘assistance for evacuation. and need special assistance.
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| STREET ADDRESS
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PHONE NUMBER cet)
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