PSN Registration

Personal Information for Individual with Special Needs

First Name:*

Middle Name:

Last Name:*

Suffix:

Date of Birth:*

Gender:*

Height (FT):*

Height (IN):

Weight (LBS):*

Email Address:

Primary Language:*

Home Address

Street Address:*

Unit / Apt:

City:*

State:*

Zip Code:*

Residence Type

Name of Subdivision/Condo/Mobile Home/Apartment Complex

Mailing Address

Same As Home Address

Street Address:*

Unit / Apt:

City:*

State:*

Zip Code:*

Phone Information

Do you have a phone?*

Yes

No

Emergency Contact Information

Do you have a Primary Emergency Contact?*

Yes

No

Do you have a Secondary Emergency Contact?*

Yes

No

Caregiver Information

Do you have a Caregiver?*

Yes

No

Providers

Physician Name:

Provider Physician Phone:

Pharmacy Name:

Provider Pharmacy Phone:

Home Health Agency:

Provider Home Health Phone:

Medical Equipment Provider:

Provider Equipment Phone:

Oxygen Provider:

Provider Oxygen Phone:

Community Based Service Organization

Community Based Service Organization Phone:

Transportation Information

Transportation Required?*

Yes

No

Unsure

PLEASE CHECK ALL VEHICLE TYPES THAT CAN BE USED FOR TRANSPORTATION.

Car can be used

Ambulance can be used

Wheelchair Accessible Van must be used

Needs to be transported on a Stretcher

Continuous Oxygen is required during transportation*:

Yes

No

Number of Family Members (living in your home) who will accompany you to shelter.

Mobility

Are there mobility issues?*

Yes

No

The person is Confined to bed.

The person is paralyzed (complete or partial).

A wheelchair is required for travel.

An Attendant is needed to assist in mobility/ ambulating.

Select all devices that are used to aid mobility:

Cane

Standard Wheelchair

Motorized Wheelchair

Scooter

Equipment Information

Medical Conditions (Check all that apply)

Service Animals/Pets

Do you own an animal?*

Yes

No

Type of Animal*:

Service Type*:

Animal's Name:*

Description/Breed:

Weight:

Is there a carrier/cage available for this animal:*

Yes

No

Is there a leash available:*

Yes

No

Is there a muzzle available:*

Yes

No

Registered Animals
Type	Service	Name	Description	Weight	Carrier	Leash	Muzzle	Remove

Acknowledgements

Information Provided By:*

Statement 1:

It is crucial in our efforts that the information provided be as accurate and up to date as possible. You will be contacted periodically to verify and ensure the information provided is correct and make any necessary changes when needed. You will be required to update your registration annually to remain active on the registry.

Statement 2:

This information will only be released to emergency response agencies for assistance during emergency and disaster situations; and I understand that emergency responders may enter my home and provide for my needs in an emergency situation.

Statement 3:

Any expenses associated for transport or admission to a hospital while in a shelter setting will be the client’s responsibility.

PSN Program Registration Form