LEE COUNTY SPECIAL NEEDS PROGRAM REGISTRATION FORM
** Registration officially turns off when Lee County enters into the 5-day forecast cone**

SPECIAL NEEDS APPLICANT – you must complete an application each year
Last Name:  _____________________          First: _________________     Date of Birth:_________
Primary language:____________________   Height: _____  ft. ______   in.     Weight: _______  lbs.
Living status:  ___ I live alone; ____ I live with spouse/relatives; ____  I live with caregiver(s);
____ Other – explain:__________________________________________________________
Address (house #):______  Street:_____________________ City:_______________ Zip: _______

Mailing Address (if different):____________________________   Subdivision: ______________

Home Phone:________________  Cell/Alt Phone: _________________
Companion/Caregiver:___________________________    Phone: __________________
Emergency contact, other than your Companion/Caregiver: ______________________________

Relationship: _________________________Phone Number: __________________________

Physician’s Name:   _____________________________     Phone Number: ______________
____   I live in a manufactured home, mobile home or trailer        ____    I am a Veteran

____  I have a pet(s).  (Note:  Service animals are allowed in all shelters.
           Pets are NOT allowed in Emergency Public or Special Care shelters)

PERSONAL HEALTH CONCERNS

____  I am visually impaired                                    ____ I am hearing impaired   

____  I have a developmental/cognitive impairment  ____ I am bowel/bladder incontinent   

____  I have unstable hemodialysis                          ____ I need help with my medications

____  I have allergies

MOBILITY / SPECIAL EQUIPMENT (check all that apply to you):

____  Cane                             ____  Walker                          ____  Wheelchair

____  Scooter (electric)           ____  Service animal               ____ Feeding tube, blender, liquid food

____  Quadriplegic                 ____  Paraplegic                      ____  Amputee

____  Oxygen dependent       ____  Nebulizer                       ____  CPAP / BiPAP

SHELTER NEEDS

____ Emergency Public Shelter    ____ Special Needs Shelter    ____ Hospital Shelter

TRANSPORTATION NEEDS

____ I will provide my own transportation to the shelter

____ I need a ride to the shelter.  I require the following type of transportation:

            ____ I can walk to a bus pickup point                       

            ____ I can walk limited distances only

            ____ I am ambulatory with assistive device

            ____ I am wheelchair / scooter bound – need handicap bus

            ____ I am bedridden – require stretcher/ambulance transport

Special Care Shelter may be required for the following conditions (please check all that apply to you):

The physician in charge of the Health Department will review each application and assign the shelter most
appropriate based upon the information provided on this application.  You must bring a Companion or
Caregiver if you are assigned to either a Special Care Shelter or Hospital Shelter.

____  Walks less than 100 feet without assistive device

____  Wheelchair bound

____  Oxygen dependent  ____ liters per minute

____  Ostomy,  ____  Foley,  ____  External catheter, ____ Self-catheter

____  Recent hospital discharge (physician/patient judgment)

____ Transfers with assistance but weighs less than 300 lbs.

____  Home peritoneal dialysis

____  Unable to make independent judgments for own welfare (i.e. Alzheimer’s, dementia, etc.)

____  Terminally ill (Hospice shelter as first preference)

____ Requires constant, reliable source of electricity

____  Chronic wounds/ulcers requiring dressing changes

____  Medical equipment required at least 4 times daily (i.e. IV pump, nebulizer, etc.)

____  Requires assistance or supervision with medications, IM or IV injections

____  Other – give details below

Hospital Shelter may be required for the following conditions (check all that apply to you):

Your doctor must send us written authorization in the form of a letter or script, dated for the current year,
stating the reasons for hospital sheltering before a shelter will be assigned.  Shelteree takes original script
or letter with him/her if evacuated.

____  Bedridden

____  Weighs more than 300 lbs. and requires personal or mechanical assistance (Hoyer) with transfers

____  Ventilator dependent

____  Combative, prone to wander, violent tendencies

____  Medical equipment other than oxygen required continuously (specify below)

Additional medical information:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

MEDICATION NOTE: If evacuated, it is important that you bring with you at least a two-week
(preferably a one-month) supply of all your medications in their original containers

(Records relating to the registration of special needs citizens are exempt from the provision of S.119.07(1), Florida Statues.)

The information contained herein is true and correct to the best of my knowledge. I have read the information
sheet accompanying this request and I understand that there are limitations on the services and levels of care
that are available.

I understand that the Special Care Shelter will be open only for the duration of the emergency.  I need
to make plans in advance for alternate living arrangements in case my home is destroyed or if I am
not able to return to my home for an extended period of time.

I understand that I may or may not be assigned to a Special Care Shelter based on the information I have
provided, available space at those facilities, and the criteria to be met for the shelter residents.   

I also understand that I will be responsible for any charges and costs associated with hospital or
medical facility care and/or medical transportation.

I hereby grant permission to medical providers, transportation agencies and others, to provide care
and respond to my needs, and for the disclosure of any information necessary to do so. I also grant
permission to emergency response agencies to enter my residence for the purpose of emergency search
and rescue, and authorize the release of information necessary for these agencies to perform these services.

In an effort to ensure the safety of all shelter residents, a background screen will be run on all people
evacuating to the Special Care Shelter, including the caretakers.  I understand this registration is
voluntary and do hereby request to be registered in the Lee County Special Needs Program. 

My submission of this form indicates I have read and understand the above instructions, and I agree
to abide by the policies set forth for the Special Needs Program and the Special Care Shelter.

Client Signature:          ___________________________     Date: _______________

If you utilize the services of a HOME HEALTH PROVIDER, NURSE REGISTRY, or
DURABLE MEDICAL EQUIPMENT PROVIDER, you may provide their contact information below.

Company / Provider:               ______________________________________________
Provider Contact Name:          _____________________________________________

Contact Phone No. _____________________________________________

Lee County Special Needs Program
Lee County Emergency Management
PO Box 398, Fort Myers, FL 33902-0398
239-533-3640  voice
239-477-3636  fax