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Special Needs Registry Form

  1. Where do you plan to stay during an evacution
  2. Can you get to an evacuation shelter?
  3. If no check (one) for the appropriate transportation needed
  4. Will a caregiver accompany you to the shelter?
  5. Please check all special needs you may have:
  6. Leave This Blank:

  7. This field is not part of the form submission.