PSN Registration Form

First Name

Last Name

Home Address

Apt/Lot No.

City

State

Zip Code

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

Same as Physical Address

Mailing Address

Apt/Lot No.

City

State

Zip

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 Name

Caregiver Phone

Do you require 24 hour caregiver?

YES
NO

Will your caregiver travel and/or stay with you?

YES
NO

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

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?

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

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

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

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

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

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

Please enter any additional information that may be useful for our emergency personnel to evacuate this person.