"No Person Left Behind"
Hurricane & Disaster
Registration Form
 

Please PRINT and fill out the requested information below in case of Hurricane or Disaster, assistance may be provided by any agencies who are assisting in this emergency.

If you need information in alternate formats (i.e. braille, tape or large print) please contact publications-request@nopersonleftbehing.org or you can call 239 368 6846.

 

Date Submitted
Last Name
First Name
Middle Name
Address
City
State
Zip Code
County
Email Address
Home Phone
Work Phone
Cell Phone
Do you use a TTY?
If so, what is the TTY Number?
Nearest Cross Streets
Please Enter Local Emergency Contact Information
Name of Nearest Local Emergency Contact
Phone Number of Local Emergency Contact
Please Enter ALTERNATE Emergency Contact Information
Person outside of the local area not impacted by this emergency
Phone Number of Alternate Emergency Contact
Please enter information about you and your disability
Gender
Age
Type of Disability
Functional Limitations or Impairments
Please enter information about your service animal
Do you have a Service Animal?		(enter Yes or No)
Type of Service Animal?
Does your Service Animal have an ID?		(enter Yes or No)
Name of Agency Issuing Service Animal ID
Name of Service Animal
If you use a manual wheel chair, power chair, or scooter – please enter a – yes, if not leave blank (click as many as applies)
Do you use a manual wheel chair?		(enter Yes or No)
Do you use a power chair?		(enter Yes or No)
Do you use a scooter?		(enter Yes or No)
Can you use a manual wheel chair, in case of an Emergency?		(enter Yes or No)
Enter Information about your doctor in case of emergency
Name of Doctor
Phone Number of Doctor
Address of Doctor
Enter Information about your family situation
Do you live with family?
Do you live alone?
List names of family living with you
If you drive enter the following information
Type of vehicle
License Plate of Vehicle
In case of an Emergency will you be needing transportation		Before	(enter Yes or No)
		After	(enter Yes or No)
Enter information about your living situation
Type of Dwelling you live in? (Check One)
Condo		What Floor?
Apartment		What Floor?
Single Residence
Duplex Residence
Mobile Home
Manufactured Home
If you have shutters for your residence, do you need help putting them up for the hurricane?		(enter Yes or No)
Enter information about what type of water system you have
Well
City
Who is your water supplier
Phone Number of your water supplier
Enter information about your electric company
Who is your electric company?
Phone Number of your electric company
Enter information if you have a generator for use
Do you have a generator that use in case of power loss?		(enter Yes or No)
What size is your generator?
Comments not listed above:
If you are registered with your local county Special Needs Program, Please list the county and agency you are listed with below. This can be from any county (Lee, Charlotte, Collier, Hendry, Glades)
Are you registered with your county agency?		(enter Yes or No)
County Registered with
Name of agency you are listed with

This form can be completed online at: NoPersonLeftBehind.org

And it will be emailed to: registration@nopersonleftbehind.org

Mailing Instructions:
Place this form in an envelope and mail to the following address:

No Person Left Behind
704 Homer Ave North
Lehigh Acres, Florida 33971
(239) 368-6846

Please make a copy for your records.

DISCLOSURE:

By Voluntarily submitting this form: I grant permission to medical providers and transportation and others, to provide care and to discloser of any information necessary to respond to my needs. I hereby grant permission for the release of this information to the emergency response agencies and also pre-authorized these agencies to enter my residence for the purpose of emergency search and rescue.