ST. JOHNS COUNTY

EVACUATION ASSISTANCE REGISTRATION FORM

St. Johns County Emergency Management | 100 EOC Drive | St. Augustine, FL 32092
Phone (904) 824-5550 | Fax (904) 824-9920 | www.sjcemergencymanagement.org

St. Johns County Emergency Management

The Evacuation Assistance Program is for citizens of St. Johns County who need sheltering assistance during a disaster. Shelters should be your refuge of last resort if you have absolutely nowhere else to go.
Residents of nursing homes, convalescent homes, retirement homes, assisted living facilities, or other group facilities, do not qualify for registration in this program. Under Florida State Statute 252 these facilities are required to have a Comprehensive Emergency Plan to evacuate their residents to a predetermined location outside the evacuation area.

This form must be completed in full, and signed, or it will be returned to you. Please print clearly.

PERSONAL INFORMATION:

New Registrant: Yes No

Today's Date:

Last Name:

First Name:

MI:

Gender:

Date Of Birth:

Age:

Weight:

lbs.

Does you weight require special transportation: Yes No

Physical Address:

Street

City

Zip

Mailing Address:

Street / Post Office Box

City

Zip

Telephone Number:

Area Code / Primary Phone Number

Area Code / Secondary Phone Number

Living Situation:

Alone - w/Spouse -

w/Other -

Residence Type:

House/Apartment - Mobile Home/RV -

Primary Language:

EMERGENCY CONTACT INFORMATION: (List all that apply)

(Primary) Name:

Relationship:

Phone:

(Secondary) Name:

Relationship:

Phone:

Home Health/Hospice Care:

No Yes

Agency:

Phone:

Live in caregiver:

No Yes

Agency:

Phone:

MEDICAL INFORMATION: (Check all that apply)

Dementia
- Moderate - Advanced

Alzheimer's Disease
- Early / Moderate - Advanced

Mental Health Impaired
- Controlled - Uncontrolled

- Hearing Aids - Deaf - Legally Blind - Speech Impaired

Wheelchair
- Electric - Manual / Standard

- Cane
- Walker

Bedridden

Could sleep on cot/air mattress in disaster situation: Yes No

Incontinence
- Bladder - Bowel

Ostomy Care
- Colostomy - Ileostomy

Dialysis Dependent
→ times per week

Catheter Line

Feeding Tube

Intravenous Line

BiPAP Machine

CPAP Machine

Nebulizer Machine

Cardiac VAD System

Oxygen Concentrator | Tank

Ventilator

- ALS / Amyotrophic Lateral Sclerosis

- Multiple Sclerosis

- Parkinson's Disease

Additional Medical Information:

TRANSPORTATION INFORMATION:(Check all that apply)

Can you / or someone drive you to an Evacuation Shelter:

Yes

No

Is someone going to the Evacuation Shelter with you: Yes No Name:

If you need transportation, what type do you need:

Car / Bus: Wheelchair Van: Stretcher Van:

SERVICE ANIMAL INFORMATION (Florida Statute: F.S 413.08 (1) d) | PET INFORMATION: (Check all that apply)

Service Animal

Service Animal Type:

- Dog - Miniature Horse

Do you have Household Pets that need to be sheltered: -No -Yes

Type and number of pets:

Animals not permitted at shelters: Exotics, Farm Animals, Wildlife

Applicant Signature & Health Insurance Portability and Accountability Act (HIPAA)

I certify that this information is correct. I understand that based on this application and the data I have provided, the St. Johns County Department of Emergency Management (SJCEM) will determine which emergency evacuation assistance, if any, this program may be able to provide. I understand that there is no cost associated with using any of the County’s disaster evacuation centers or disaster transportation services. "However, should my medical condition deteriorate and should I need advanced medical treatment during transportation to or while populating a St. Johns County evacuation shelter I understand I will be responsible for all charges incurred as a result." I grant permission to medical providers, transportation agencies and other individuals providing me medical care and disclose any information required to respond to my needs.

HIPAA Privacy Rule: As defined in the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule of 1996, by signing this Authorization, I hereby allow the use or disclosure of my medical information by SJCEM, in order to provide me assistance during emergency evacuations.

I understand that information used or disclosed pursuant to this Authorization, may be subject to disclosure by the recipient for the purposes of evacuation, sheltering, transportation and any medical care pursuant to these services.

I understand that I have the right to revoke this Authorization at any time except to the extent that SJCDEM has already acted in reliance on the Authorization. To revoke this Authorization, I understand that I must do so by written request to:

St. Johns County Department of Emergency Management
100 EOC Drive
St. Augustine, Florida 32092
Attention: Evacuation Assistance Registry

I understand that if I choose to revoke this Authorization, I will no longer be part of the Evacuation Assistance Registry and will not be evacuated.

Electronic Authorization:

Person Completing Form:

Relationship: