Emergency Evacuation Registration Form

	The South Kingstown Police Department has developed a registry of seniors and people with special needs who would like to receive evacuation and shelter assistance during natural disasters like hurricanes or severe flooding. This is a free, voluntary registration. The information you provide will be confidential, in accordance with state law. It will be used by emergency personnel only to assure your safe and timely evacuation. Please fill out the questionnaire below and click submit at the bottom when complete. A copy of your registration form will be automatically emailed to the South Kingstown Police Department. Fields marked with a * are required.
Registration Form
NAME: * first: * last: middle: sex: male   female primary language: ADDRESS: * street: apartment: * city: * zip: telephone: ttd/tty: NEXT OF KIN OR GUARDIAN: name: telephone: RESIDENCE: number of people in residence: - - - - - - - - - - - - - - - - - - type: single family apartment/condo mobile home - - - - - - - - - - - - - - - - - - pets: yes   no type of pet(s): - - - - - - - - - - - - - - - - - - seasonal resident: yes   no if seasonal, which dates: from to HEALTHCARE: are you receiving home health care: yes   no name of agency: agency phone: - - - - - - - - - - - - - - - - - - special needs: (check all that apply) physically disabled legally blind hearing impaired total hearing loss speech impaired other:   - - - - - - - - - - - - - - - - - - physical limitations: wheelchair use walker confined to bed - - - - - - - - - - - - - - - - - - life support system: oxygen respirator electrical other:   is life support system portable: yes   no hours in the day life support is in use: - - - - - - - - - - - - - - - - - - special transportation needs: lift gate vehicle ambulance other:   - - - - - - - - - - - - - - - - - - special diet: yes   no type of diet: - - - - - - - - - - - - - - - - - - closed captioned TV service: yes   no