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HomeMy WebLinkAboutAppendix 1-22, Evac Registration FormAppendix 1-22 – Evacuation Call Center Group - Evacuation Registration Form City of Beaumont Evacuation Registration Form Local ID Number: _______________ Date of Registration: Time of Registration: Do you have transportation to evacuate? Engine Company District: Do you have transportation to the staging area? Last Name: First Name: Date of Birth: Age: Address: Apt.# City: Zip: Phone Number: Male? Female? Contact Last Name: Contact First Name: Contact Phone Number: Relationship: If others are evacuating with you, how many? Do you have pets or service animals? How many? Type: Do you have special medical needs? Do you only need transportation to evacuate? 0 Are you dependent on others or in need of others for routine care (eating, walking, toileting, etc.? 1 Are you blind, hearing impaired, deaf/blind, or do you have an amputation? 2 Are you in need of assistance with medical care administration, monitoring by a nurse, help with equipment, assistance with medications, or care for a mental disorder? 3 Are you someone living outside of an institutional facility that requires extensive medical oversight? 4 Are you living in an institution, such as a hospital, long-term care, assisted living facility of state school? 5 Is an ambulance required for evacuation? Do you have a care giver? List additional Evacuees at this address, including Care Givers. Last Name: First Name: Male Female Age: Last Name: First Name: Male Female Age: Last Name: First Name: Male Female Age: Last Name: First Name: Male Female Age: Comments: Appendix 1-22 – Evacuation Call Center Group - Evacuation Registration Form City of Beaumont Evacuation Registration Form Local ID Number: _______________ Date of Registration: Time of Registration: Do you have transportation to evacuate? Engine Company District: Do you have transportation to the staging area? Last Name: First Name: Date of Birth: Age: Address: Apt.# City: Zip: Phone Number: Male? Female? Contact Last Name: Contact First Name: Contact Phone Number: Relationship: If others are evacuating with you, how many? Do you have pets or service animals? How many? Type: Do you have special medical needs? Do you only need transportation to evacuate? 0 Are you dependent on others or in need of others for routine care (eating, walking, toileting, etc.? 1 Are you blind, hearing impaired, deaf/blind, or do you have an amputation? 2 Are you in need of assistance with medical care administration, monitoring by a nurse, help with equipment, assistance with medications, or care for a mental disorder? 3 Are you someone living outside of an institutional facility that requires extensive medical oversight? 4 Are you living in an institution, such as a hospital, long-term care, assisted living facility of state school? 5 Is an ambulance required for evacuation? Do you have a care giver? List additional Evacuees at this address, including Care Givers. Last Name: First Name: Male Female Age: Last Name: First Name: Male Female Age: Last Name: First Name: Male Female Age: Last Name: First Name: Male Female Age: Comments: