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