The information that I have provided is true and accurate to the best of my knowledge, and I am submitting this application voluntarily. I understand that my contact information and information about my personal medical information may be provided to local, county, state and federal agencies for the purposes of emergency planning and emergency response to better serve my needs in an emergency.
I understand that my submission of this Special Needs Registration Form does NOT guarantee assistance in an evacuation or sheltering.
I authorize emergency personnel to enter my home, if necessary, to assist me and ensure my safety and welfare during an emergency.
