APPLICATION TO REGISTER FOR THE SPECIAL NEEDS PROGRAM
Lee County Emergency Management, Attention Debbie Quimby, P.O. Box 398, Fort Myers, FL 33902-0398
FOR INFORMATION CALL (239) 533-0640 / FAX # (239) 477-3636


Applications will NOT be processed when Lee County is in the 5-day forecast cone.


Special Needs Applicant – You must complete an application each year (please type or print):

Last Name:

First Name:

Date of Birth:

Primary Language:

Height:

ft.  in.

Weight:

lbs.




    

House Number:

Street/Unit #:

City:

Zip:

Mailing Address:

Subdivision:

Home Phone:

Alt/Cell Phone:


Companion/Caregiver Name:

Companion/Caregiver Phone:

Emergency Contact, other  
than Companion/Caregiver:

Relationship:

Emergency Phone:

Physician's Name:

Physician's Phone:



Shelter & Transportation Needs: (please check one box in each column only)

I need a Shelter: I need a Shelter & a Ride:
Type of Transportation Needed Personal Health Concerns





You must have a Companion/Caregiver if assigned to either a Special Care Shelter or a Hospital.


Recommended Level of Care – check all that apply
The physician in charge of the Dept. of Health will review and assign to the appropriate shelter based on stated criteria.

Special Care Shelter for the Following Conditions:
Hospital Care for the Following Conditions:
Your doctor must send us written authorization before you can be sheltered in a hospital

NOTE TO DOCTOR:
A copy of your letter/script (separate from this form) must be dated current year & included with this application stating the reason patient must be evacuated to a hospital in event of hurricane. Patient takes original with him/her if evacuated.

Suggested/Preferred Hospital:


Mobility/Special Equipment:
     

Additional medical information:

MEDICATION NOTE: If evacuated, it is important that you bring with you at least a two-week supply
(preferably one-month supply) of all your medications in their original containers!

Records relating to the registration of special needs citizens are exempt from the provision of S.119.07(1), Florida Statues.


I will bring my cat / dog to the shelter. I will bring to the shelter with me a collar and leash, crate, food and water, vaccination records, clean-up supplies, and any medications that my pet requires. Please provide the quantity and weight of the pet(s) you are bringing in the fields below.

Dog(s) - how many? Cat(s) - how many?
Weight of dog(s): Weight of cat(s):

The information contained herein is true and correct to the best of my knowledge. I have read the information sheet accompanying this request and I understand that there are limitations on the services and levels of care that are available.

I understand that the Special Care Shelter will be open only for the duration of the emergency. I need to make plans in advance for alternate living arrangements in case my home is destroyed or if I am not able to return to my home for an extended period of time.

I understand that I may or may not be assigned to a Special Care Shelter based on the information I have provided, available space at those facilities, and the criteria to be met for the shelter residents.

I also understand that I will be responsible for any charges and costs associated with hospital, medical facility care and/or medical transportation.

I hereby grant permission to medical providers, transportation agencies and others, to provide care and respond to my needs, and for the disclosure of any information necessary to do so. I also grant permission to emergency response agencies to enter my residence for the purpose of emergency search and rescue, and authorize the release of information necessary for these agencies to perform these services.

In an effort to ensure the safety of all shelter residents, a background screen will be run on all people evacuating to the Special Care Shelter, including the companion/caretaker. I understand this registration is voluntary and do hereby request to be registered in the Lee County Special Needs Program.

My submission of this form indicates I have read and understand the above instructions, and I agree to abide by the policies set forth for the Special Needs Program and the Special Care Shelter.


Client Signature:

Date:

If you utilize the services of a HOME HEALTH PROVIDER, NURSE REGISTRY, or DURABLE MEDICAL EQUIPMENT PROVIDER,
you may provide their contact information below.

Company /Provider:

Provider Contact Name:

Contact Phone No.


Lee County Emergency Management, Attention: Debbie Quimby P.O. Box 398, Fort Myers, FL 33902-0398
FOR INFORMATION CALL (239) 533-0640 / FAX # (239) 477-3636