Citizens with Special Needs Form

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Southport Police Department Citizens with Special Needs Form

Date(Required)

Type of Report(Required)

Initial/Register

Change

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Mobile Home?(Required)

Yes

Directions to Home (please provide landmarks)(Required)

Phone Number(Required)

TDD/TTY Number

Date of Birth(Required)

Sex(Required)

Language(Required)

English

Spanish

Vietnamese

Creole

Other (please specify below)

Language (if selected "other" above)

Special Needs or Concerns (please select ALL that apply)(Required)

Mobility (bedridden, wheelchair bound, cane/walker use)

Insulin Dependent

Lives Alone/Limited Family Support

Sight Impaired (Blind/Limited Vision)

Hearing Impaired (Deaf/Hard of Hearing)

Speech Impaired

Dependent on Electricity for Medical Equipment

Respirator User

CPAP (or other breathing machine)

Dialysis User

Oxygen User (please provide oxygen company and contact info below)

If selected "Oxygen User" above, please provide oxygen company and phone number

In the event of evacuation, I will be(Required)

staying at home

going to a public shelter

staying with family or friends

I need transportation(Required)

Yes

Primary Physician(Required)

First Last

Physician's Phone Number(Required)

Medications and Medical Problems/Concerns(Required)

Emergency Contact(Required)

First Last

Emergency Contact Address(Required)

Street Address Address Line 2 City State Zip Code

Emergency Contact Phone Number(Required)

Emergency Contact Relationship(Required)

Consent

I, the undersigned, give permission for the above information to be released to the necessary agencies for assistance with evacuation and/or aid in the event of a disaster or emergency.

Signature

Date Submitted(Required)

This field is for validation purposes and should be left unchanged.

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City of Southport Contacts

Emergency: DIAL 9-1-1
Non-emergency: Police: (910) 457-7911 Fire: (910) 457-7915
City Information: (910) 457-7900
Address: Southport City Hall,
1029 N. Howe Street, Southport, NC 28461
Hours: 8:30 am - 5:00 pm
(City observes State holidays)

Fort Johnston-Southport Museum & Visitors' Center

Hours: Monday - Saturday: 10:00 am - 4:00 pm
For more information: (910) 457-7927
Address: 203 E. Bay Street, Southport, NC 28461

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