PERSONAL INFORMATION:
Last Name:
First Name:
MI:
Birth Date:
Gender:
Weight:
Height
Street Address:
City:
State:
Zip:
Phone:
Mailing Address(If different):
City:
State:
Zip:
Phone:
Name of Subdivision, MH Park, Apt Bldg., etc:
Flood Prone Area:
Temporary Address:
From:   To:  
Primary Language Spoken:
Type of Structure(check one)          
Living Situation: (check one)          
MEDICAL INFORMATION: (Check and complete those that apply to your medical condition.)
Require Life-Sustaining Medical Equipment ? (Check those that apply)
[You must bring your own equipment with you to the shelter.]




Oxygen – Type:
             
How Often
Rate            (liters/min)
Amount used per day?
How is it given?              

Check any of the following that apply to you




  How Often?


(Explain)

     
     
     
     
     
     
(Explain)

(Explain)
. Require equipment to help with mobility?
  
  
  
Bedridden
    

    
    
    
    
Equipment used to assist with  impairment


Other

(Explain )


Medication
    
    

List of all medications:


List of all other medical conditions:
EMERGENCY CONTACT INFORMATION: 1 Local and 1 Non-Local
(Local) First Name
Last Name
Relationship
Phone
(Non-Local) First Name
Last Name
Relationship
Phone
PHYSICIAN/PHARMACY INFORMATION:
Physician's Last Name:
First Name:
Phone:
Pharmacy Name:
Phone:
Home Health Care Agency Name:
Phone:
Hospice:
Phone:
Dialysis Center:
Phone:
Medical Equipment Provider:
Phone:
SHELTER INFORMATION: PET INFORMATION:
Plan on using a shelter?      
Provide Own Transportation to Shelter:     
If you need assistance with transportation, check one of the following: 
  
  
  

(Only service animals are allowed in the shelters.)

(Make arrangements for your pet with a vet, kennel, or bring your pet to our pet friendly shelter.)
Name of person going with patient to the shelter:
Relationship to patient:
Phone:
AUTHORIZATION INFORMATION:
I agree that my name be added to the Special Needs Emergency Shelter list. I give Levy County Emergency Management
authorization to share this information with other local support agencies in the event of an emergency evacuation. I also grant emergency response personnel permission to enter my home during search and rescue operations following a disaster, if necessary, to assure my safety and welfare.



Patient Signature: ________________________________________________________________     Date: ___________________


Authorized Signature: ____________________________________________________________     Date: ___________________


Relationship to Patient: ___________________________________________________________     Date: ___________________

Mail Form to: Levy County Emergency Management, PO Box 221, Bronson, FL 32321 (352) 486-5213
EMERGENCY MANAGEMENT USE ONLY:
Previous Application:      

Approved: Denied: Reason:
Initials:
9/10/08