Part 1:  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:

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:          Height-Ft     Height-In
Do you live in? Do you live?
House Alone
 Apartment  With spouse
 Mobile Home With children
 Senior Living Facility Other
Other
*Do you require the use of a TDD/TTY?:YesNo
*Do you speak English?:YesNo     *Language spoken in the home:

*Emergency Contact Name:

*Phone:  *Email:

You must provide at least one phone number for your emergency contact name.  Both fields can not be blank.

  Relationship:

Do you have a Medical Service Animal?YesNo   Type:  

(Copy of vaccination records must be presented when you are transported)

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

   PETS: All pets must have the required vaccinations.  Owners are responsible for the pet's medication, collars and leashes.

If you plan to have your pet evacuated please provide the necessary information:

Name of Pet

Type of Pet

Weight

Pet Needs/Marking

Special Needs -  The following information will help us provide appropriate transportation and medical care if needed during and assisted evacuation. 

Do you have transportation?      YES NO

If transportation is needed, can you handle steps on a bus? YES NO

If not will you need a wheelchair lift? YES NO? 

  Can you transfer from mobility scooter or wheelchair to a standard vehicle seat? YESNO
  Can you sit in a wheelchair and hold your own weight of your body? YESNO
 
 Part 2: Medical Needs Transportation: 
MEDICAL NEEDS: (check those that apply)
Manual Wheelchair/Electric Wheelchair
Walker or Cane ( walks with assistance:)
Other - If checked, please specify equipment:           
Oxygen Dependent - I understand I need to bring enough oxygen to support my needs during
      travel
Insulin Dependent Diabetic - I understand I need to bring enough insulin to support my needs
     during travel
Hearing Impaired
Blind with a Guide Dog?
Daily Wound Care - Do you require special isolation or quarantine?
Daily Tube Feedings (If checked please bring pump and formula for five days)
Dialysis
Other Medical
 
SPECIAL NEEDS:(check those that apply)
Suction Machine                                          
Portable Ventilator                                      
 Bedridden                             
CPAP/BIPAP
Central Line                                                 
Unable to walk                                              
Unable to sit upright                                                                 
Cardiac Disease         
 Daily IV Meds                                    
 Oxygen Dependent (24 hours )                                     
 Apnea Monitor                                       
Stroke/Brain Injury
Paralysis
Contracted
 
MEDICATION LIST

Please bring list of current medications including name, dosage and how often  you take the medicine along with a seven (7) to ten (10) day supply.

 
PHYSICIAN INFORMATION

Please bring a list of all current treating physicians including name, address, phone number, and type of hospital affiliation
 
ASSISTANCE REQUIRED:
Transportation to a shelter needed: YesNo
                  Check needs:
                                             Bus
                                             Car
                                            Wheelchair Van
                                             Ambulance
In the event of disaster, please check one of the following:
Staying at home - Staying with relatives or friends
Public Shelter - Needs can be met in a non-medical facility
Special Needs Shelter - Requires special monitoring and assistance

Other information that you think we at Jefferson Parish will need to know about?

 

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 name ( Print):
Witness signature: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
 
If submitted by outside agency, please select outside agency name
Facility    Phone Number