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2. The Town maintains a confidential database for residents who would need special sheltering for a physical or medical condition during a disaster or emergency. If you are unable to stay in a regular shelter, please complete this Special Needs Application.

4. Applicant

6. Last Name*
8. First Name*
10. Middle Initial
12. Street Address*
14. Apartment Number
16. Hamlet*
18. Telephone Number*
20. Year Round Resident

    1. Yes
    2. No

22. Emergency Contact

24. Last Name*
26. First Name*
28. Middle Initial
30. Street Address*
32. Apartment Number
34. City*
36. State*
38. Zip Code*
40. Relationship*
42. Telephone Number*

44. Details

46. Condition or Disability*
48. Special Equipment and/or Medications*
50. Ambulatory?*

    1. Yes
    2. No
52. Fire District
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field