Please complete the Special Needs Registration Form if you or someone close to you has a disability or special need and would require help to evacuate in an emergency.
By submitting a completed card now, the Linn County Emergency Management Agency can better prepare for an evacuation.
Special Need Registration Form
Information provided will be kept confidential. You should complete a registration card yearly.
Please check mark any of the boxes that apply
Part-time resident (specify which months at this address)
Deaf or hearing impared Blind or sight impared
TDD Telephone Number
Confined to a wheelchair
Could transfer to regular seats in a bus or van with assistance
Confined to a bed
List electric powered medical devices you use (if any)
Special emergency assistance required
(check only those applicable)
Special notification of the event
Transportation if evacuation is required
Alternative emergency contact person:
Relationship to person needing assistance:
What Kind of Help Would You Need?
I need to be led to safety.
I need TDD or other special emergency warning notification.
I need special transportation to evacuate like an ambulance or handicapped accessible bus.
I need a family member or someone assigned to me in a shelter.
I need electricity for medical equipment.
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Linn County Emergency Management Agency, 6301 Kirkwood Blvd. S.W., Cedar Rapids, Iowa 52404