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2. 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.
4. Transportation: Complete this section so that we can determine the transporation needs for resident.
6. Do you have a transportation need in the event of an emergency or evacuation?*

   1. Yes
   2. No
7. Do you have friends or family that can assist you in evacuation?*

   1. Yes
   2. No
9. Check which best applies to individual needing assistance.*

   1. Use cane or walker
   2. Cannot walk- Needs a wheelchair to be moved.
   3. Bedridden or medical equipment-must have ambulance transport.
11. Special/Functional Needs

    1. Hearing impaired
    2. Visually impaired/ring doorbell

    1. Speech impediment
    2. Use service animal

    1. Oxygen dependent
    2. Life support dependent

    1. Cognitive/memory impairment
    2. Other (explain in comments)
13. Comments:
15. Contact Information for Person Needing Assistance
17. Name*
18. Email Address (optional)
20. Address*
22. City*
23. State*
24. Zip Code*
26. Please list either a home number, a cell number, or both.
28. Home Number
29. Phone - Check any that apply to home phone

    1. Text
    2. TTY
    3. VP
31. Cell Number
32. Mobile - Check any that apply to mobile phone

    1. Text
    2. TTY
    3. VP
34. Contact Me:

    1. I would like to register to receive notifications in the case of an emergency in my area. We will need an email and phone number for notifications.
36. Emergency Contact Information #1
37. Emergency Contact Information #2
39. Name*
40. Name*
42. Home Number*
43. Home Number*
45. Work Number (optional)
46. Work Number (optional)
48. Cell Number (optional)
49. Cell Number (optional)
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field