Form Center

The county’s Online Form Center allows you to electronically submit and/or print requests for information and other forms.
By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Request for Special Assistance

  1. If you have a disability or special/functional need that will require assistance during an evacuation or emergency situation, please fill out this form and submit to York County Office of Emergency Management. Provisions have been made to provide transportation to those who need it, but it is very important those needs are identified before an emergency. Local authorities will keep this information confidential, and this form will need to be resubmitted annually. Please remember this form is only for evacuation and emergency situations where evacuation might be necessary. For 9-1-1 related information please contact York County Public Safety Communications.

  2. Transportation: Complete this section so that we can determine the transporation needs for resident.

  3. Do you have a transportation need in the event of an emergency or evacuation?*

  4. Do you have friends or family that can assist you in evacuation?*

  5. Check which best applies to individual needing assistance.*

  6. Special/Functional Needs

  7. Contact Information for Person Needing Assistance

  8. Please list either a home number, a cell number, or both.

  9. Phone - Check any that apply to home phone

  10. Mobile - Check any that apply to mobile phone

  11. Contact Me:

  12. Emergency Contact Information #1

  13. Emergency Contact Information #2

  14. Leave This Blank:

  15. This field is not part of the form submission.