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.

Name:

Address:

City:

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)

 Other

Special emergency assistance required

(check only those applicable)

 Special notification of the event

 Transportation if evacuation is required

Alternative emergency contact person:

Name:

Relationship to person needing assistance:

Daytime telephone:  

Nighttime telephone: