Lake County Department Of Public Safety/emergency Management Division Special Needs Registry Form Page 2
ADVERTISEMENT
1
2EMERGENCY CONTACT INFORMATION:
First Name:
Last Name:
Relationship:
Phone:
First Name:
Last Name:
Relationship:
Phone:
PHYSICIAN/PHARMACY INFORMATION:
Physician's Last Name:
First Name:
Phone:
Pharmacy Name:
Phone:
SHELTER INFORMATION:
PET INFORMATION:
If pets will be accompanying you to the shelter, check
Will you provide your own transportation to the
□
□
Yes
No
the appropriate box and indicate how many.
shelter?
If you need assistance with transportation, check one of the types
□
of transportation you need:
Cat __________
□
□
Dog __________
automobile
□
□
Guide Dog __________
van w/wheelchair lift
□
□
Other (Explain )________________________
stretcher
Name of person going with client to the shelter:
Phone:
COMMENTS:
AUTHORIZATION INFORMATION:
OPTIONAL: PREAUTHORIZATION TO ENTER HOME BY EMERGENCY PERSONNEL
I authorize emergency response personnel to enter my home during search and rescue operations following a disaster, if
necessary, to assure my safety and welfare.
Authorized Signature:
I, (Print Name )
understand that all of my medical records are confidential, exempt from the public records law, and not to be disclosed to
anyone without my consent or that of my guardian pursuant to section 455.241, Florida Statutes.
I hereby provide my consent for the members of the Lake County Emergency Management Office to have access to the
medical information contained in this form.
I understand that this form is not a reservation for the Special Needs Shelter but that my medical information will be utilized
to determine/assess plans appropriate for my care and treatment during an emergency.
I further understand that only those persons who have a need to know this information, will have access to it. This release
remains in effect until further notice unless revoked by me in writing.
Authorized Signature:
Date:
Print Name of Person Completing This Form If Other Than Client:
Phone:
Mail form to: Lake County Emergency Management, 425 W. Alfred St., PO Box 7800, Tavares, FL 32778-7800 (352) 343-9420
Revised 09/28/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical