Special Needs

Emergency Special Needs

A person requiring any type of assistance during an emergency situation is classified as someone with a Special Need . If you have some type of "Special Need", please fill out the following form or print this special needs form and return it to our office; or you may contact the Department of Emergency Management at (352)-486-5213 and we will mail one to your home for you to fill out and return.

It is important to fill out this form completely and as accurately as possible to insure that we can meet your specialized needs in an efficient manner.

Once you are registered for the Special Needs Assistance Program, we ask that you help us in helping you by keeping us informed of any changes to your needs. We can not keep your information accurate and up to date if we are not notified. It is also important that if you no longer need our help or if you are moving that you notify us.

If you need Special Help in an Emergency. Please print information.

My Name is:		Date of Birth:
Address:
City:		FL Zip:
Phone:
Mailing Address (if different):
City:		FL Zip:

I require special assistance during an emergency of the following type:

Transportation (example: No car, wheelchair...)
Medical Care (Condition that req. nursing care, Oxygen dependent, ..)
Emergency Care (Ambulance transport, Hospital care, Dialysis…)

Please fill out this card and place it in the mail immediately! Someone will be contacting you to get more information and to discuss options or a plan for you during an emergency.

Levy County Emergency Management
P.O. Box 221
Bronson, FL. 32621