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Special Needs

  1. SOUTHOLD EMERGENCY MANAGEMENT

    SPECIAL NEEDS AND EVACUATION FORM

  2. Local Resident*

    Are you a resident of Southold?

  3. Pets

    Do you have any pets that will need to be sheltered?

  4. Transportation Required*

    Will you need transportation to the shelter?

  5. Emergency Contact Number

    Supply the name of an individual that could be contacted if necessary.

  6. List any information about your health that will help us understand how to assist you.

  7. List any special equipment that is required for your condition.

  8. Legal Disclaimer

    While it is the goal of the Town of Southold to serve its special needs residents in the event of an emergency, the Town makes no guarantee or warranty that such services will be provided. Nothing contained in this form is intended to or should be construed as creating any obligation or duty on the part of the Town to provide any special or additional services to those individuals providing the information requested herein, or to the public generally.

  9. Leave This Blank:

  10. This field is not part of the form submission.