Orange County Government, Florida

PSN Program Registration Form


This form is for new registrations only. If you are providing an update to an existing registration, please contact Orange County 311 at (407) 836-3111.

Personal Information for Individual with Special Needs

Home Address

Mailing Address

Phone Information

Emergency Contact Information

Caregiver Information

Providers

Transportation Information

Mobility

Select all devices that are used to aid mobility:

Equipment Information

Select all equipment used:

Medical Conditions (Check all that apply)

Service Animals/Pets

Acknowledgements

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.

Additional Comments

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