Special Needs Registry Models

Coconino County and Yuma County have developed a special needs registry for individuals that may
need evacuation assistance. Both Coconino and Yuma counties have a special needs registration
form for individuals to self register.
People with special needs are individuals who have a physical, cognitive, and/or sensory disability,
and/or medical care needs who, after exhausting all other resources (family, neighbors, etc.) still need
assistance before, during, and after a disaster or emergency.
Coconino County Special Needs Registry
The Coconino County Health Department, Public Health Emergency Preparedness team has
developed a confidential Special Needs Shelter Registry that individuals who feel may need the
services of a Special Needs Shelter may preregister online, by telephone, or mail. Coconino County
Health Department is also continuing to work with the media and various human services agencies to
enroll individuals who may have special medical needs.
Coconino County Special Needs Registration Form
Please note that this information will be kept confidential and will be used and maintained by [to be determined].
By providing this information, you are authorizing the information contained herein to be released to the CCHD
and the Coconino County Emergency Services office. Registration does not guarantee availability of medical
treatment in the shelter.
Name: (last)___________________________ (first)____________________________ (MI)________________
Phone:_________________________________ Alternate Phone:_____________________________________
Home Address:_____________________________________________________________________________
Apt. Number (if applicable):____________________Complex Name:__________________________________
Special Directions to your Home:_______________________________________________________________
Mailing Address: ___________________________________________________________________________

Care Giver Information
Care Giver Name:________________________________ Care Giver Phone: ___________________________
Address:________________________________________ Care Giver Relationship:______________________
Notes/Comments:___________________________________________________________________________
_________________________________________________________________________________________
_
Health Information: Please check all that apply
____ Kidney Disease

___ Emphysema

____ Breathing Treatment

____ Feeding Tube

____ Diabetes/insulin depend

____ Memory impaired

____ Walker/Cane

____ Ventilator

____ High blood pressure

____ Heart Disease

____ Sight impaired

____ Bedridden

____Dialysis

____ Service Dog

____ Incontinence

____ Stroke

____ Speech impaired ____ Oxygen

____Cancer

____ Hearing impaired ____ Geri chair

Additional Information:___________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
______________
Medications: ______________________________________________________________________________
Notification Information
Emergency Contact
Name:_________________________________Phone:__________________________________
Doctor’s Name: _________________________Phone:__________________________________

______________________________________________________________________________
Office Use Only
Date:__________________________________________________________________________
Name of Recorder:_______________________________________________________________
Notes:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Yuma County Special Needs Registry
The City of Yuma administers a Special Needs Registry in coordination with the Yuma County Health
Department. Registration is done through meetings with local organizations, hospitals, nursing homes,
and other population centers. A “Request for Disaster Evacuation” form includes information about the
special needs individual’s name, date of birth, physical address, emergency contact person, telephone
number, and special evacuation requirements.

Yuma County Special Needs Registration Form
REQUEST FOR DISASTER EVACUATION
Name/Nombre: _____________________________________________________
Date of Birth:
month ______ day _______ year _______
Fecha de Nacimiento: mes ______ día ________ año _______
Physical Address: ____________________________________________________
Dirección de su Casa: _________________________________________________
Emergency contact person not living with you:
Teléfono de una persona que no viva con usted para avisarle en caso de Emergencia
Your Phone # ____ _____________
Teléfono # ____ _____________

SPECIAL EVACUATION REQUIREMENTS
_____ Wheelchair/Silla de ruedas
_____ Ambulance/Ambulancia
_____ Hand Held Assist Only/ Asistencia personal
_____ Service animal/ Mascota de servicio
_____ Other important information/ Otra información importante

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