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Special Needs, Functional Needs, or Transportation Needs Notification

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Steps

  1. 1. Step One
  2. 2. Person Needing Aid
  3. 3. Description of Needs
  4. 4. Designated Helpers
  5. 5. Conclusion

  • Step One

    2. Notice
      Do not include any sensitive information on this form or (if applicable) files uploaded to this form. Sensitive information includes, but is not limited to, social security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.
    4. Purpose
      This form mirrors the functional needs card that is published in the yearly mailer to the community. Those who may need special accommodations during a major disaster or during an evacuation should fill out this card. Family members and close friends of those needing assistance are encouraged to help their loved one fill out this electronic form, the handwritten card, or sign up for B-WARN!. All of these methods cause us to enter the person's contact information into our contact list in B-WARN! that we use during a disaster. Only one method needs to be filled out to get on our list. This list is only good for one year. You must update the list yearly.
    6. By submitting this form, you are agreeing to share your data to emergency management for the purpose of helping you during a disaster. Emergency Management will hold the information confidential and only share your information with agencies who work in the emergency operations center.
    8. Person filling out form*
      Are you filling this form out for:
    23. Type Name of Organization you represent if your Organization offers service to help others fill out this form.