Special Needs Evacuation Registry

This is a free, voluntary registration. The information you provide will be confidential, in accordance with state law. It will be used by emergency personnel only to assure your safe and timely evacuation. Your registration will be included in the Mobile County Special Needs Registration coordinated by Volunteer Mobile, Inc.

All information contained in this form is confidential and can be made available only to other emergency response agencies in order to provide required assistance.

Questions marked with a * are required.

 
*1. First Name
 
*2. Last Name
 
*3. Address
 
*4. City
 
*5. State
 
*6. Zip
 
*7. Do you live in:
House
Apartment
Mobile Home
Other: 
 
8. Name of Subdivision, Mobile Home Park, Apartment Building, or Lot #
 
9. Closest intersection
 
*10. Living Situation (check one)
Live Alone
With Spouse
With Children
Other: 
 
*11. Do you require the use of TDD? (Telecommunications Device for the Deaf)
Yes
No
 
*12. Do you receive home health care?
Yes
No
 
13. If so, please select the agency:
Alacare Home Health & Hospice
Amedisys Home Health of Mobile
Gentiva Health Services
Infirmary Homecare of Mobile
Saad's Health Care Services
Springhill Home Health and Hospice
Vanguard Home Health of Mobile
Other: 
 
*14. Home Phone
 
15. Cell Phone
 
16. E-mail Address
 
17. Marital Status
Single
Married
Divorced
Separated
Widowed
Other: 
 
18. Spouse's Name
 
*19. Numer of people in home
 
*20. Language spoken in home
English
Spanish
French
Laotian
Cambodian
Vietnamese
German
American Sign Language
Other: 
 
*21. When is the best time to contact you?
7:00 AM-3:00 PM
3:00 PM-11:00 PM
Anytime
Never
 
22. If you are leaving due to an emergency/disaster, do you:
have a reliable car
have a someone to ride with
need transportation
go to a pick-up station on your own
 
*23. Do you have a service (seeing eye) dog?
Yes
No
 
*24. Special Need Information. Please check all that apply to you:
Speech impairment
Hearing impairment (deaf or hard of hearing)
Sight impairment
Memory loss/mental impairment
Totally bedridden
Full-time (24/7) skilled nursing care required
None
 
Medical Needs Information (Only individuals with one or more of these is allowed at the Medical Needs Shelter. All evacuees who enter the Medical needs Shelter must bring a caregiver who will remain at the shelter with the patient. Due to limited space, only one person may accompany the Medical Needs evacuee.)
 
*25. Please check all that apply to you:
Portable ventilator
STABLE oxygen, nebulizer, or sleep apnea treatments
Foley/Supra-pubic catheter
Frequently incontinent (urinary/bowel)
Ostomies
Mild dementia: non-abusive or wandering behavior
Mental illness with nonviolent behavior
Peritoneal dialysis - home-managed, self-administered or family administered(caregiver who administers treatment must accompany patient)
None
 
*26. Birthdate
(e.g. 4/21/2002)
 
*27. Height
 
*28. Weight
 
*29. What portable equipment will you bring with you to the shelter: (please check all that apply)
IV Pole
Portable Ventilator
Oxygen Concentrator
Oxygen Tank
Dialysis Machine
Suction Machine
None
Other: 
 
*30. What will you bring for mobility
Manual Wheelchair
Electric Wheelchair
Walker or cane
Service animal (seeing eye dog)
Need assistance to ambulate
None
Other: 
 
If you are completing this information for someone else, please provide the following information:
 
31. Name
 
32. Title
 
33. Agency
 
34. Phone
 
35. E-mail
 
36. Relationship to registrant
 
*37. Due to time and limited resources to safely evacuate people with special needs, the evacuation process may be executed well in advance of an impending disaster. You must be ready to evacuate when told to do so by emergency officials! The Mobile County Special Needs Registry in no way replaces the responsibility of individuals to have their own emergency plan.

Voluntary Submission Notice:
I am submitting this information voluntarily. I give Volunteer Mobile, Mobile County Emergency Management Agency and the Mobile County Health Department authorization to maintain and share this confidential information with local support agencies for use only in the event of an emergency. During such emergency, I am giving local emergency personnel permission to enter my home, if necessary, to assure my safety and welfare.
I have read and understood the Voluntary Submission Notice.