Special Needs Residents

Special Needs Registration

In order to provide proper care to Citizens with handicaps, disabilities or other special requirements during times of emergencies, we are asking you to complete this form so that we may be aware of your needsIf you know of someone who would require assistance getting to an emergency shelter, please urge themto complete this form. If you have questions, you may contact Emergency Management at 508-285-0240

All information on this form is strictly confidential


STREET ADDRESS__________________________________________APT #____________

PERSON COMPLETING THIS FORM________________________PHONE#___________

EMERGENCY CONTACT__________________________________PHONE#____________

Check all that apply

___I would arrange my own transportation to a shelter in an emergency

___ I would require transportation but could walk a short distance to a Bus stop

___ I have limited mobility and would require help on and off the Bus

___ I am confined to a wheelchair and would need a wheelchair van

___I would require Ambulance transportation

___I am Deaf ____I use a TTY/ TDD

___I am Blind ____I have a guide dog

___I require electric power for life support equipment. What equipment?_____________

___I have specialized medical or other requirements, describe______________________


Mail to or drop off at Town Hall Norton Emergency Management Agency

70 East Main St Norton, Ma. 02766