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Special Needs Evacuation Assistance Registration

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Personal Information

Assistance Information

Special Need Shelter Only

Emergency Contacts


By filling out this form and clicking submit, I give my authorization for the medical information contained herein to be released to the county health department, emergency management, local fire districts, and receiving facilities for the purpose of evaluating my needs and providing emergency transportation and sheltering. Records relating to registration of disabled citizens are exempt for the provisions of Indiana Code 5-14-3, Public Records Law. The information contained here will be kept confidential.

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