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Special Needs Form

Please correct the field(s) marked in red below:

Special Needs Form

If you have any questions or need any assistance with this online submit form, please email us or call 706-868-3303.   

NOTE:  Please complete all information on the form below. 

Your Name:
 *
Your Name:
Contact Information:
 *
Contact Information:
Sex
Sex

Secondary Contact Information
Secondary Contact Information
Secondary Contact Information (con't)
Secondary Contact Information (con't)
Identify Two Local Emergency Contacts
Identify Two Local Emergency Contacts
Impairments:
Impairments:
Medical Conditions:
Medical Conditions:
Walking Ability:
Walking Ability:
Mental Condition:
Mental Condition:
Equipment Needs:
Equipment Needs:
Method of Transport:
Method of Transport:
Special Notes: (Explain your need for assistance in an evacuation or power outage situation and list any severe allergies that you may have)
Hospital of Preference
Hospital of Preference
Where your medical records are currently kept:
Where your medical records are currently kept:
Information Provided By:
Information Provided By:
Relationship
Do you give permission for this information to be shared with the county 911 service?
Do you give permission for this information to be shared with the county 911 service?
If you are, or should become dependent on electrical medial equipment, may we share only your name, address, phone number, & type of equipment with Georgia Power Co.?
If you are, or should become dependent on electrical medial equipment, may we share only your name, address, phone number, & type of equipment with Georgia Power Co.?
Someone may be contacting you in the near future regarding your submission if we have any questions.
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