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
NAME_______________________________________________PHONE#________________
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