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Send Completed to Form to: Augusta-Richmond County Emergency Management Agency 911 4th Street Augusta, Georgia 30901 [PHONE REDACTED] People With Special Needs Database Client Information Sheet Name Male Female Address City State Zip County Telephone Alternate Phone E-mail Address Date of Birth Height Weight Directions to individual’s home (include subdivision name, if applicable): Nearest emergency contact outside of household: Relative Neighbor Friend Name Address City Telephone Local Emergency Contacts Name Telephone Name Telephone Name Telephone Page 1 of 2 ---PAGE BREAK--- Please check all that apply: IMPAIRMENTS MENTAL CONDITION WALKING ABILITY Visually Impaired Alert Independent Hearing Impaired Semi-confused Needs assistance Speech Impaired Confused Unable to walk Non-English Speaking Not Conscious MEDICAL CONDITION EQUIPMENT NEEDS METHOD OF TRANSPORT Catheter/Ostomy ____Oxygen ____Car Cardiac Nebulizer ____Wheelchair accessible transport Stroke Condition Respirator Stretcher transport Seizures Suction Ambulance only Diabetic IV Asthma Dialysis Paraplegic Tube Feeding Quadriplegic Walker/Crutches/Cane Special Diet Wheelchair (WC) Dementia Working Animal (Seeing eye dog, etc.) Other Please list any other medical conditions not listed above, or any severe allergies that you may have: Physician Name’s Telephone Hospital of Preference Location your medical records are kept The following information is critical; please answer, sign, and date. The release of this information will in no way affect your service(s). We are releasing this information only for the purpose of disaster planning. Do you give permission for this information to be shared with your County 911 Service and your local Emergency Management Agency (EMA)? Yes No If you are, or should become, dependent on Electrical Medical Equipment, may we share only your name, address, phone number, and type of equipment with Georgia Power Company or your local electric company? Yes No Sign Here: Date Signed: Page 2 of 2