Special Needs Registration Form - Town Of Old Lyme

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Help Us to Help You in an Emergency!
Town of Old Lyme Special Needs Registration Form
Name:
Phone:
Address:
Emergency Contact Name:
Phone:
I may need assistance in case of an evacuation for the following reasons:
(Please Circle “YES” or “NO” for each response)
Sight Impaired
YES
NO
Hearing Impaired
YES
NO Confined to bed
YES
NO
Need a Wheel Chair Ride YES NO
Use TDD/TTY
YES NO Using Oxygen
YES
NO
Need a Ride for Evacuation YES
NO Using a Machine to Help You Breathe
YES
NO
Any other medical equipment that needs electricity to keep you alive? YES
NO
Description of equipment___________________________________________________
Service Animals
YES
NO
Pets
YES
NO
Type
DOG
CAT
OTHER
Number of Pets:
Will the Pet be coming with you?
YES
NO
Help Us to Help You in an Emergency!
Town of Old Lyme Special Needs Registration Form
Name:
Phone:
Address:
Emergency Contact Name:
Phone:
I may need assistance in case of an evacuation for the following reasons:
(Please Circle “YES” or “NO” for each response)
Sight Impaired
YES
NO
Hearing Impaired
YES
NO Confined to bed
YES
NO
Need a Wheel Chair Ride YES NO
Use TDD/TTY
YES NO Using Oxygen
YES
NO
Need a Ride for Evacuation YES
NO Using a Machine to Help You Breathe
YES
NO
Any other medical equipment that needs electricity to keep you alive? YES
NO
Description of equipment___________________________________________________
Service Animals
YES
NO
Pets
YES
NO
Type
DOG
CAT
OTHER
Number of Pets:
Will the Pet be coming with you?
YES
NO

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