Anderson County Special Needs Registry

Anderson County

Confidential- Emergency Supports Request
If you have a disability that requires additional assistance during an emergency, please fill out this form as soon as possible.

This information will be kept confidential by state and local authorities.

This is NOT intended for residents who live in long-term care facilities or residential treatment facilities.

Please Note - A new form should be submitted each year in order to keep our records current.
Have you completed this form before?
Name of Person with Special Need*

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Email

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Phone # of person with special need*
Please enter a valid phone number.
Can your primary phone number receive text messaging? *
I am completing this form for someone else:*
Contact Me:

I would like to discuss my special assistance needs in the event of an emergency.I would like to register to receive calls in the event of an emergency in my area.
Preferred method of contact:

EmailTextPhone CallMailOther (Please Specify)
Please check off each box that applies to you:

I do not have transportation available to leave the area during an emergency evacuationI use a cane or walker, but can ride in a van, bus or car.I am in a wheelchair and would need a wheelchair van.I would need to ride in an ambulance.I am deaf or hard of hearing.I have difficulty understanding or expressing languageI require the use of a communications deviceI am visually/sight impaired and require help.I require and use a service animal.I have special medical equipment and require special transportation (Explain Below)I have a diagnosis of AutismI am oxygen dependentOther (Please Explain)
If you have a TDD or TTY number please provide it below.
Please enter a valid phone number.
Add a Photo (optional)

Cancelof
Emergency Contact Information

Person who can be contacted in the event you have an emergency:
I wish for this person to be contacted in the event of an evacuation notice:
Name of Emergency Contact*

First NameMiddle NameLast Name
Emergency Contact Phone #*
Please enter a valid phone number.
Can your primary phone number receive text messages?*
Alternate Phone Number
Please enter a valid phone number.
Address of Emergency Contact if Different from Above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Person Completing Form

First NameLast Name
Should be Empty:

Anderson County

Emergency Contact Information