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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.

Name: _______________________________________________________________
Telephone Number: (Include Area Code)
Home:_____________________ Work:________________________________

Name : _____________________________________________________________________

Street Address: ______________________________________________________________
State: ______ Zip: ___________
Telephone: _________________
TTY: _________________

If you are completing this card for someone else, please include your name and telephone number too.

Person completing this card - _____________________
Telephone: ____________________________________

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!

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