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.




Telephone Number:

Please check mark any of the boxes that apply

 Full-time resident

 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:

Daytime telephone:  

Nighttime telephone: 

© 2009 Linn County EMA


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.

Links or references to individuals or companies does not constitute an endorsement  or guarantee of any information, product, or service you may receive from such sources.

Linn County Emergency Management Agency, 6301 Kirkwood Blvd. S.W., Cedar Rapids, Iowa 52404