ST. JOHNS COUNTY
EVACUATION ASSISTANCE REGISTRATION FORM

St. Johns County Emergency Management | 100 EOC Drive | St. Augustine, FL 32092
Phone (904) 824-5550 | Fax (904) 824-9920
Online Registration: www.sjcemergencymanagement.org
       
 
The Evacuation Assistance Program is for citizens of St. Johns County who need sheltering assistance during a disaster situation. Shelters should be your refuge of last resort if you have absolutely nowhere else to go.
Residents of nursing homes, convalescent homes, retirement homes, assisted living facilities, or other group facilities, do not qualify for this program because under Florida State Statute 252 it is required these facilities have an Emergency Plan to evacuate their residents to a predetermined location outside the evacuation area.

This form must be completed in full, and signed, or it will be returned to you. Please print clearly.

PERSONAL INFORMATION:                      New Registrant:   Yes     No          Today's Date: 

Last Name:       First Name:       MI: 

Sex:       Date Of Birth:     Age: 

Height: (ft.) (inc.)   Weight:  lbs.    Does you weight require special transportation:  Yes  No

Physical Address:             
Street City Zip
Mailing Address:             
Street / Post Office Box City Zip
Telephone Number:    /  
Area Code / Primary Phone Number Area Code / Secondary Phone Number

Email Address:      

Primary Language:      Secondary Language: 

Living Situation:      Alone -       w/Spouse -       w/Parents -       w/Children -       w/Other -
Residence Type:      House/Duplex -       Mobile Home/RV -       Apartment/Condo-      
EMERGENCY CONTACT INFORMATION: (List all that apply) 
(Cargiver) Name: Relationship:  Phone:
(Local) Name: Relationship:  Phone:
(Non-Local) Name: Relationship:  Phone:
Receiving Home Health Care:
No      Yes
Agency:
   
Phone:
Receiving Hospice Care:
No      Yes    
Agency:
   
Phone:
Live in caregiver:
No      Yes    
Name:
   
Phone:

   I Have No Medical Needs - I Need Transportation Only
         If you have no medical needs, proceed to the transportation section.

MEDICAL INFORMATION:  (Check all that apply)
Anxiety/Depression Alzheimer's Disease Mental Health Impaired
Dementia/Confusion - Early/Moderate - Controlled
- Advanced - Uncontrolled
Hearing Impaired Vision Impaired Speech Impaired
- Hard of hearing - Glasses
- Hearing Aids - Legally Blind
- Deaf
Mobility Impaired Wheelchair Amputee
- Cane - Electric Paraplegic
- Walker - Manual / Standard Quadriplegic
    Bedridden       Could sleep on cot/air mattress in disaster situation:   Yes     No
Cardiac ALS - Amyotrophic Lateral Sclerosis     Epilepsy
- Pacemaker Multiple Sclerosis Seizures
- VAD System Parkinson's Disease
Incontinence Ostomy Care Diabetic
- Bladder - Colostomy - Diabetic Diet
- Bowel - Ileostomy - Insulin Dependent
Catheter Line Dialysis Dependent
A times per week
Feeding Tube Intravenous Line
Asthma Sleep Apnea COPD
- Nebulizer - BiPAP Emphysema
- CPAP
Oxygen Dependent Tank Ventilator
- Continuous Use     Concentrator
- Intermittent Use

Medications:   

Additional Medical Information:   


TRANSPORTATION INFORMATION:(Check all that apply)

Can you drive yourself to a Shelter: Yes  No
Can someone drive you to a Shelter: Yes  No
Is someone going to the shelter with you: Yes  No Who: 

If you need transportation, check the type of transportation you need us to provide:
Car / Bus:       Wheelchair Van:       Stretcher Van:       Other:

PET / SERVICE ANIMAL INFORMATION: (Check all that apply)

Animals not permitted at shelters: Exotics (primates, snakes, etc.), Spiders and Insects, Farm Animals

  Guide/Service Animal     Service Animal Breed / Type: 
Do you have pets that need to be sheltered: -No  -Yes    Type and number of pets:

Applicant Signature & Health Insurance Portability and Accountability Act (HIPAA)

I certify that this information is correct. I understand that based on this application and the data I have provided, the St. Johns County Department of Emergency Management (SJCDEM) will determine which emergency evacuation assistance, if any, this program may be able to provide. I understand that there is no cost associated with using any of the County’s disaster evacuation centers or disaster transportation services. However, should my medical condition deteriorate and should I be admitted to the hospital, while being evacuated or at an evacuation center, then I will be responsible for the charges incurred once I am “admitted as a patient” of a hospital. I grant permission to medical providers, transportation agencies and other individuals providing me medical care and disclose any information required to respond to my needs.

HIPAA Privacy Rule: As defined in the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule of 1996, by signing this Authorization, I hereby allow the use or disclosure of my medical information by SJCDEM, in order to provide me assistance during emergency evacuations.

I understand that information used or disclosed pursuant to this Authorization, may be subject to disclosure by the recipient for the purposes of evacuation, sheltering, transportation and any medical care pursuant to these services.

I understand that I have the right to revoke this Authorization at any time except to the extent that SJCDEM has already acted in reliance on the Authorization. To revoke this Authorization, I understand that I must do so by written request to:

St. Johns County Department of Emergency Management
100 EOC Drive
St. Augustine, Florida 32092
Attention: Evacuation Assistance Registry

I understand that if I choose to revoke this Authorization, I will no longer be part of the Evacuation Assistance Registry and will not be evacuated.


Electronic Authorization:
Person Completing Form:             Relationship: