Special Needs Check List
If you have a disability that may cause you to need
special help in an emergency, please fill out and return this card as soon as
possible. If someone you know in the area would need special help in an
emergency, urge him or her to complete and return this card. The information
will be kept confidential and only be used in case of emergency.
Please check off each box that applies to you:
I do not have transportation available to leave the area in an emergency.
I need help but can ride in a van or bus.
I am in a wheelchair and need a wheelchair van.
I have specialized medical equipment and require special transportation.
I am deaf or hearing impaired and use a TTY.
I am sight-impaired and require special help.
I require a medically prescribed diet.
I require and use a Service Animal.
Other (Please explain.) _____________________________________________
There is a person you may contact to help me in an emergency.
Telephone Number: (Include Area Code)
Name : _____________________________________________________________________
Street Address: ______________________________________________________________
State: ______ Zip: ___________
If you are completing this card for someone else, please include your name and
telephone number too.
Person completing this card - _____________________
Return this completed form to:
Don't forget to stock up on your family's emergency food supplies as well as read up on up-to-date resources available to you in times of an emergency!