Special Needs Registration

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.

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Special Need Registration Form

Information provided will be kept confidential.  You should complete a registration card yearly.

Your Name (required)

Address (required)

City (required)

Phone (required)

Please check mark any of the boxes that apply
 Full-time resident Part-time resident
If part-time which months at this address?

 Deaf or hearing impared Blind or sight impared TDD Telephone Number

 Confined to 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

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