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ABOUT US
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311 Help & Info
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PSNRegistration
PSN Registration Form
Personal Information for Individual with Special Needs
First Name
Last Name
Home Address
Apt/Lot No.
City
State
Zip Code
Single Family Home
Mobile Home
Multi-Family Home
Apartment
Other
Name of Subdivision/Condo/Mobile Home/Apartment Complex
Primary Phone
Secondary Phone
Primary Phone is TTY/TTD
I Do Not Have A Phone
Email Address
Date of Birth
Gender
MALE
FEMALE
Transgender
Non-Binary
Prefer Not To Answer
Height (ft)
Inches
Weight (lbs)
Primary Language
Mailing Address (Please enter if Different than your Physical Address)
Same as Physical Address
Mailing Address
Apt/Lot No.
City
State
Zip
Emergency Contact(s) Information
Primary Contact
First Name
Last Name
Relationship
Primary Phone
Secondary Phone
Checking this box allows medical information to be shared with this contact.
Secondary Contact
First Name
Last Name
Relationship
Primary Phone
Secondary Phone
Checking this box allows medical information to be shared with this contact.
Caregiver and Family Information
Caregiver Name
Caregiver Phone
Do you require 24 hour caregiver?
YES
NO
Will your caregiver travel and/or stay with you?
YES
NO
Medical Providers
Physician's Name
Physician's Phone
Pharmacy Name
Pharmacy Phone
Home Health Care Agency Name
Home Health Care Agency Phone
Medical Equipment Provider Name
Medical Equipment Provider Phone
Oxygen Provider Name
Oxygen Provider Phone
Transportation Needs
If transportation assistance is required, please check all vehicle types that can be used for transportation.
Car
Bus
Van
Ambulance
Stretcher
Do you require continuous Oxygen During Transport?
YES
NO
How many family members (
who live in your home
) will accompany you if you choose to seek shelter?
Mobility Needs
Do you have mobility needs?
YES
NO
Confined to Bed
Paralyzed
Partial Paralysis
Complete Paralysis
Wheelchair
Attendant to assist in ambulating
Select all devices that are used to aid mobility:
Walker / Cane
Standard Wheelchair
Motorized Wheelchair
Motorized Scooter
Equipment Needs
Are you dependent on Electrical Equipment?
YES
NO
Are you Oxygen Dependent?
YES
NO
Oxygen Type
Gaseous
Liquid
Oxygen Mode
Mask
Nasal Cannula
Trach Collar
Liter Flow
Frequency
24 Hours
Only Overnight
As Needed
Select All Equipment Used:
Apnea Monitor
CPAP/BIPAP
Cardiac Monitor
Catheter
Dialysis Catheter
Feeding Pump
Feeding Tube
Hoyer Lift
Medications that Require Refrigeration
Nebulizer
Oxygen Concentrator
Pulse Oximeter
Suction Pump
Tracheostomy Tube
Ventilator
Wound Vac
Other Equipment
Medical Conditions (Select All that Apply)
Alzheimer Disease
Mild
Severe
ALS
Early Stage
Middle Stage
Late Stage
Aphasia
Assistance with Daily Living
Asthma
Arthritis
Autism
Behavioral Health
Blind / Low Vision / Vision Impaired
Cancer
Chemotherapy
End Stage
Palliative
Radiation
Remission
Surgical
Cardiac
Stable
Unstable
Cerebral Palsy
COPD
Comatose
Contagious Disease
Cystic Fibrosis
Deaf / Hard of Hearing
Dementia
Mild
Moderate
Severe
Diabetes
Insulin Dependent
Non-Insulin Dependent
Dialysis
At Facility
At Home
Peritoneal
Frequency
Two times a week
Three times a week
Eating and Swallowing Disorder
Edema
Emphysema
Fractured Bones
Frail Elderly
High Blood Pressure
Hip / Knee Replacement
Non-Ambulatory
Confined to Bed
Incontinence
IV Care
Mentally / Memory Impaired
Multiple Sclerosis
Muscular Dystrophy
Neuromuscular Disorder
Ostomy
Paralysis
Parkinson's Disease
Seizures
Sleep Apnea / CPAP User
Speech Impediment
Stroke
Terminal Endstage
Wounds / Sores / Rashes
Other
Service Animals / Pets
Do you own an animal?
YES
NO
What type of animal?
DOG
CAT
Miniature Horse
Other
Is this animal a service animal (eg. a seeing eye dog)?
YES
NO
Is this animal a emotional support animal?
YES
NO
Animal's Name
Breed/Description
Weight
Is there a carrier cage available?
YES
NO
Is there a leash available?
YES
NO
Is there a muzzle available?
YES
NO
Add a Second Animal or Pet
Do you own an animal?
YES
NO
What type of animal?
DOG
CAT
Miniature Horse
Other
Is this animal a service animal (eg. a seeing eye dog)?
YES
NO
Is this animal a emotional support animal?
YES
NO
Animal's Name
Breed/Description
Weight
Is there a carrier cage available?
YES
NO
Is there a leash available?
YES
NO
Is there a muzzle available?
YES
NO
Additional animals/pets should be listed in Comments.
Additional Comments/Information
Please enter any additional information that may be useful for our emergency personnel to evacuate this person.
Security Code:
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