Special Needs Response Card

If you need transportation or any other assistance during an emergency, please fill out this Response form and send it now.  In an emergency, you would be picked up at your home by local emergency workers.  This information will be kept confidential.

Name:

  

 

Address:

  

 

Apartment #:

  

 

City:

  

 

Village:

  

 

Township:

  

 

State:

  

 

Zip Code:

  

 

Phone Number:

  

 

TDD No.
(if applicable):

  

 

Fire District
(if known):

  

 

Special needs. Please check appropriate box and specify assistance requested.

 

Hearing impaired
 

 

 

Visually impaired
 

 

 

Special transportation for disabled
 

 

 

No access to TV

 

 

No access to radio

 

 

Other

 

In the event a condition listed above changes, please advise your county emergency management agency or submit a Special Needs Removal Card.

Return this information to the emergency management agency in your county. A new form should be submitted once each year, so that records can be continually updated.

To send by mail, print this form and send it to one of the following addresses:

Geauga County
Department of Emergency Services
12518 Merritt Road
Chardon OH 44024

Lake County
Emergency Management Agency
P. O. Box 480
Mentor OH 44061-0480

Ashtabula County
Emergency Management Agency
25 West Jefferson Street
Jefferson OH 44047