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 any citizen of St. Johns County who needs assistance during a disaster situation requiring evacuation to a Public Shelter or a Special Needs Shelter. A Special Needs Shelter is capable of providing limited medical care only. If you require ambulance transportation and / or hospital facilities you or your care-giver should make those arrangements ahead of time. Shelters should be your refuge of last resort if you have absolutely no where else to go.

Residents of nursing homes, convalescent homes, retirement homes, assisted living facilities, or other group facilities, will look to the management of their facility for an organized group evacuation. 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.

All records, data, information, and correspondence relating to the registrants of the Evacuation Assistance Program are confidential and exempt from disclosure and can be made available only to other emergency response agencies (Section 252.355, Florida State Statute).

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

PERSONAL INFORMATION:

NEW REGISTRANT:   Yes     No          REGISTRANT UPDATE:   Yes     No          TODAY'S DATE: 

LAST NAME:      FIRST NAME:      MI:        SEX: 

DATE OF BIRTH:      AGE:      HEIGHT: (ft.) (inc.)       WEIGHT:  lbs.

PHYSICAL ADDRESS:      CITY:      ZIP:   

MAIL ADDRESS:      CITY:      STATE:      ZIP: 

TELEPHONE NUMBER:       ALTERNATE NUMBER: 

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:

    No Medical Needs-Need Transportation Only

MEDICAL INFORMATION:  (Place a check by all that apply to you)
    Alzheimer's Disease     Dementia     Senility
    Anxiety/Depression     Mental Health Impaired         controlled     uncontrolled
    Blind     Deaf     Speech Impaired
    Guide/Service Animal Service Animal Type: 
    Mobility Impaired     Cane/Walker     Wheelchair
    Bedridden Could sleep on cot/air mattress in disaster situation:   Yes     No
    Cardiac     Pacemaker     VAD System/LVAS System
    Diabetic Diet     Insulin Dependent     Dialysis Dependent
    Incontinence     Bladder     Bowel        A times per week
    Multiple Sclerosis     Parkinson's Disease
    Catheter Line     Intravenous Line     Feeding Tube
    Ostomy Care     Ileostomy     Colostomy
    Asthma            Nebulizer            COPD            Emphysema
    Sleep Apnea     BiPAP     CPAP
    Oxygen Dependent     Intermittent Use     Continuous Use
    A  type of oxygen used         Tank     Concentrator

ALLERGIES:

MEDICATIONS:

TRANSPORTATION INFORMATION:(List all that apply)

CAN YOU DRIVE YOURSELF TO A SHELTER:    YES:       NO: 
CAN SOMEONE DRIVE YOU TO A SHELTER:     YES:       NO: 

IF NO, CHECK THE TYPE OF TRANSPORTATION YOU NEED US TO PROVIDE:
CAR/BUS: WHEELCHAIR VAN: STRETCHER VAN: OTHER:
DO YOU HAVE PETS:    No     Yes     If yes, type and number of animals:

PERSON COMPLETING FORM:       RELATIONSHIP: