Special Needs - Client Information

*Required field - Please fill in a valid value for all required fields

Please do not use special characters when entering the below information. (ex: ' & %)

*Email Address: *Date:

If you do not have an email address, enter N/A in this field.

*First Name:*Last Name:

*Home Phone:*Cell Phone:

You must provide either your home phone number or your cell phone number.  Both fields can not be blank.

 *Street Address:

Only Jefferson Parish residents can apply for the Jefferson Parish Assisted Evacuation Assessment Registry

*City:*Zip: Lot#:Apt#: Weight:

*Emergency Contact Name:*Phone:

*Email:*Relationship:

Is transportation to a shelter needed? Yes No

Check needs:   Bus       Car        Wheelchair Van        Ambulance

MEDICAL NEEDS: (Check those that apply)

Oxygen Dependent - I understand I need to bring enought oxygen to support my needs during travel

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.

Manual/Electric Wheelchair Walker or Cane Unable to walk 
Hearing Impaired   Blind with a Guide Dog Stroke/Brain Injury
Portable Ventilator  Suction Machine Apnea Monitor
Bedridden CPAP/BIPAP Contracted
Paralysis Dialysis Unable to sit Upright
Daily IV Meds    Central Line  

Other Explain:

Do you have a Medical Service Animal?Yes    No                   Type

Do you have any pets that will require transportation? Yes No

PETS: All pets must have the require vaccinations. Owners are responsible for the pet's Medication, Collars and Leashes.

Name of  Pet:   Type of Pet:

Pet Weight:                                        Pet  Markings:

Voluntary Submission Notice:

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 voluntarily.

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 notice

Signature:   Date:

Witness Signature: Print Witness Name:

Witness Date:

Relationship to above individual:

Personal Care Assistant that will be accompanying you to the Special Needs Shelter:

Care Givers Name:Phone:

Relationship Age:

Sex: Male Female

2019