DINGMAN TOWNSHIP EMERGENCY OPERATIONS PLAN

 

SPECIAL NEEDS ASSISTANCE FORM

 

In case of an emergency (natural disaster where an evacuation may or may not be needed), this emergency management office will need to know if there are any people with special needs in your home or office. The Emergency Management Office will arrange to have the Special needs person assisted. We cannot help if you do not inform us.

 

Please check all that may be applicable;

 

___      NON ENGLISH SPEAKING

 

___      SPECIAL ALERT NOTIFICATION

 

___      NON AMBULATORY RESIDENT (AMBULANCE REQUIRED)

 

___      SPECIAL MEDICAL NEEDS

 

___      OTHER

 

In the area below please describe the nature of the special need (s) along with directions to your home if necessary. Please use the reverse side if more room is required.

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

MAILING ADDRESS

 

PHYSICAL ADDRESS

 

DEVELOPMENT

 

PHONE NUMBER

 

 

Mail or drop off  this completed form to:

 

Dingman Township

Emergency Management Office

118 Fisher Lane

Milford, Pennsylvania 18337