*Required field - Please fill in a valid value for all required fields
Please do not use special characters when entering the below
information. (ex: ' & %)
If you do
not have an email address, enter N/A in this field.
*First Name:*Last Name:
*Home Phone:*Cell Phone:
provide either your home phone number or your cell phone number. Both
fields can not be blank.
Only Jefferson Parish
residents can apply for the Jefferson Parish Assisted Evacuation Assessment
*City:*Zip: Lot#:Apt#: Weight:
*Emergency Contact Name:*Phone:
Is transportation to a shelter needed?
Check needs: Bus Car
Wheelchair Van Ambulance
MEDICAL NEEDS: (Check those that apply)
Dependent - I understand I need to bring enought oxygen to support my needs
Insulin Dependent Diabetic - I understand I need to bring
enough insulin to support my needs during travel
Daily Tube Feedings (If checked please bring pump and
formula for five days)
Daily Wound Care - Do you require special isolation or
quarantine. Bring all supplies needed.
Do you have a Medical Service Animal?Yes
Do you have any pets that will require transportation?
PETS: All pets must have the require vaccinations. Owners are
responsible for the pet's Medication, Collars and Leashes.
Name of Pet:
The Jefferson Parish Special Needs registry in no way replaces the
responsibility of individuals to have their own emergency plan.
I am submitting this information
I give Jefferson Parish
authorization to maintain and share this information with local support agencies
and State of Louisiana and Federal Emergency Management/Homeland Security
Agencies for use only in the event of an emergency.
During such emergency, I am giving
local emergency personnel permission to enter my home, if necessary, to assure
my safety and welfare.
I have read and understood the voluntary submission
Relationship to above individual:
Personal Care Assistant that will be accompanying you to the Special Needs
Care Givers Name:Phone: