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..

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.

 
Client Information
 
*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. Are you supported by a home health care provider?
Yes
No
 
13. The name of the home health provider/agency (if you answered yes to the previous question)
 
Contact Information
 
*14. Home Phone
 
15. Cell Phone
 
16. E-mail Address
 
17. Spouse's Name
 
*18. Numer of people in home
 
Emergency Contact Information
 
19. Relationship
 
20. Name
 
21. Telephone
 
*22. Language spoken in home
English
Spanish
French
Laotian
Cambodian
Vietnamese
German
American Sign Language
Other: 
 
Evacuation Plan Information
 
*23. Do you have a service animal (seeing eye dog)?
Yes
No
 
*24. Do you need specialized transportation such as a chairlift, etc?
Yes
No
 
*25. 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.)
 
*26. 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)
IV Treatments - home-managed, self-administered or family administered(caregiver who administers treatment must accompany patient)
None
 
Additional Information
 
*27. Birthdate
(e.g. 4/21/2002)
 
*28. Height
 
*29. Weight
 
*30. 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: 
 
*31. 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:
 
32. Name
 
33. Title
 
34. Agency
 
35. Phone
 
36. E-mail
 
37. Relationship to registrant
 
*38. Prior to evacuating, you will receive a call verifying your need to move to a shelter. Only leave with individuals you know or who have official credentials to transport you. For more information, call UCP Mobile at (251) 479-4900.

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 UCP 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.
 
*39. Please indicate if this is a:
New Application
Update