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2. Disclaimer
   I understand that completion of this form is merely to assist with an emergency response and in no way guarantees an emergency response or special priority during an emergency or disaster. I understand in the event of an emergency or disaster, if I need assistance, Emergency Management will prioritize use of pertinent county resources in accordance with county policy. Therefore, I give Emergency Management authorization to share this information with other local support agencies in the event of an emergency or disaster only. I also grant emergency response personnel permission to enter my home during search and rescue operations following a disaster if necessary to assure my safety and welfare. If at any time a change is made to the enclosed information, I will contact the Calvert County Department of Public Safety, Emergency Management Division, for a new form.
4. Name*
6. Street Address*
7. City, Zip*
9. Home Phone*
10. Cell Phone*
11. Email*
13. Background information; please select all that apply:

    1. Full-time county resident
    2. Part-time county resident
    3. Deaf or hearing impaired
    4. TDD number or text messaging number
    5. Blind or sight impaired

    1. Wheelchair user
    2. Unable to leave bed
    3. Alzheimer's or dementia
    4. Mental health disability/cognitive disability
    5. Physical disability/developmental disability
14. List any critical medical devices in use:
16. List any medications:
18. List any regular treatment procedures (dialysis, etc):
20. Special emergency assistance required; please select all that apply:

    1. Transportation assistance if evacuation is required
    2. Accessible transportation if evacuation is required
    3. Specialized medical transportation before evacuation
    4. Live on the second floor or higher and will need assistance during evacuation
22. Are you able to transfer on your own to an accessible vehicle?*

    1. Yes
    2. No
23. Do you have a service animal?*

    1. Dog
    2. Miniature Horse
    3. No
25. Please list caregivers or family members who can provide you with transportation during an emergency
27. Name
28. Home Phone
29. Cell Phone
31. Name
32. Home Phone
33. Cell Phone
35. Name
36. Home Phone
37. Cell Phone
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field