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2. Notice

   Do not include any sensitive information on this form or (if applicable) files uploaded to this form. Sensitive information includes, but is not limited to, social security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.

   Purpose

    Those who may need special accommodations during a major disaster or during an evacuation should fill out this card. Family members and close friends of those needing assistance are encouraged to help their loved one fill out this electronic form. Entries to this list will be compiled into one form for emergency services to use in the event of a disaster. In the event that the person represented on the form is no longer at the residence listed, please update the form or contact the Cass County Emergency Manager's Office. 

   By submitting this form, you are agreeing to share your data to emergency management for the purpose of helping you during a disaster. Emergency Management will hold the information confidential and only share your information with agencies who work in the emergency operations center.

4. Person Filling Out Form

   I am filling this form out for:

   1. Myself
   2. Someone Else
6. Affiliation

   Type Name of Organization you represent if your Organization offers service to help others fill out this form.

8. Relationship to Person Needing Aid
10. Continue

Person Needing Aid

2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Special Directions to Get to Home
13. Home Phone Number

    Format: 111-111-1111

14. Cell Phone Number

    Format: 111-111-1111

    
    

16. Continue |Go Back

Description of Needs

2. For the person potentially needing aid, please mark ALL of the conditions that apply to the person. Please understand that be choosing to share your conditions, we will be able to better understand how to help in an emergency.

4. Access or Functional Needs

   Mark ALL that apply that would be an issue during an emergency:

   1. None of these apply.
   2. Vision impairment
   3. Ventilator
   4. Hearing Impairment
   5. Speech Impairment
   6. Oxygen
   7. Wheelchair
   8. Walker/Cane/Other Mobility Impairment
   9. Bed Confinement
   10. Service Animal
   11. Cognitive Impairment
   12. Non-English Speaking
   13. I do not wish to list impairments.
5. Transportation Needs

   Mark ALL that likely would apply during an ordered evacuation:

   1. None of these apply.
   2. Person does not have own transportation
   3. Person does not have dependable alternative transportation
   4. Person can be transported in a normal passenger vehicle (car or van with no special accommodations)
   5. Person would need a special transport vehicle (wheelchair van, etc.)
7. Pets/Animals

   Describe pets/animals this person has that would need to be cared for, evacuated with the person, or otherwise might be a concern if a disaster occurred.

9. Residency

   Does this person reside in Cass County:

   1. Full-time
   2. Part-time
   3. Not at all
11. What else do you want us to know?
13. Continue |Go Back

Designated Helpers

2. Does this person have anyone nearby who can help them in an emergency?

   1. Yes
   2. No
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Cell Number
16. Work Number
17. Work Number Extension
19. Do you want to add another helper?

    1. Yes
    2. No
21. Name
22. Email Address
24. Address
26. City
27. State
28. Zip Code
30. Phone Number
31. Cell Number
33. Work Number
34. Work Number Extension
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit | Go Back

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