Angel Bernal
Chief of Police
(415) 389-4100
(415) 389-4148 (FAX)
1 Hamilton Drive
Mill Valley, CA
94941
SPECIAL NEEDS EVACUATION REGISTRATION
This program is designed for those who have special physical/medical needs and may require government
evacuation/shelter assistance in the event of an emergency. The program requires you to enroll annually
or your information will be removed from our database. Please complete this registration and mail it to
the return address on the back of this form. This Department maintains this form and a copy will be
forwarded to the Mill Valley Fire Department and our dispatch provider, Marin County Communications,
in case of an emergency requiring evacuation.
Pursuant to HIPAA statutes, some information requested in this registration form may be confidential and
will only be made available to other emergency response agencies.
Today’s Date: ____________________
Personal Enrollment Data:
Name:___________________________________________
Last
First
Middle
Sex: M or F
(Circle one)
Street Address:_________________________________________________________________
Street
City
Mailing Address (if different from above)_____________________________________________________________
Telephone: ______________ Date of Birth:______________ Age ______ Speak English Y or N
(Cell) _____________
(Circle One)
Residence Type:[ ] House/Duplex [ ] Apartment/Condo
Living Situation: [ ] Living Alone [ ] With Spouse [ ] With Spouse & Child(ren)
[ ] With Parents [ ] With Other Relative [ ] With Non-Relative [ ] With Child(ren)
[ ] Pets
Name of Contact in your home:_________________________
Emergency Contacts
(Local) Name:__________________ Relationship:________________ Phone: ______________________
(Non-local) Name: ______________ Relationship:________________ Phone:_______________________
Person completing this Form (if different from above)___________________________________________
Address/Company______________________________________________________________________
Medical Care Information
Special Medical Needs (Check those that apply)
[ ] Medical Dependence on Electricity [ ] Memory Impaired [ ] Anxiety/Depression [ ] Mental Health
Impaired [ ] Respirator Dependent [ ] Dialysis Dependent [ ] Insulin Dependent-Self Administered? [ ]
Speech Impaired [ ] Mobility Impaired [ ] Walker/Cane/Wheel Chair
[ ] Bedridden [ ] Open Wounds [ ] Wheelchair Bound [ ] Incontinence [ ] Obesity – Weight [ ] Sight
Impaired [ ] Hearing Impaired [ ] Oxygen Dependent [ ] Service dog
[ ] Other (explain) _____________________________________________________________
Primary Doctor Name:____________________________________ Phone:________________
Home Health Agency Name:_______________________________ Phone:________________
Anticipated Date of Discharge: ______________ Reason:______________________________
Pharmacy Name:________________________________________ Phone:________________
Health Insurance Company Name:__________________________ Phone:________________
Allergies:______________________________________________________________________
Medications:___________________________________________________________________
ASSISTANCE REQUIRED
Do you have a Caregiver that could go with you? [ ] YES [ ] NO
If yes, Name:______________________________________ Phone: ______________
Do you need transportation to a Public Shelter in the Event of a Disaster? [ ] YES [ ] NO
If yes, do you need a: bus
car
wheelchair
van
ambulance
(Circle one)
NOTE: You plus one caregiver only will be given transportation.
In Case of Emergency: I, _________________________, authorize rescuers to enter my home.
(printed name)
Signature:_________________________________________________ Date _____________
This section to be completed by the Emergency Preparedness Office
PIN:__________________ Evacuation Zone:__________ Primary Handicap:_______________
Level of care needed during an emergency evacuation:
[ ] Public Shelter – Needs can be met in a non-medical facility.
[ ] Medical Supervision Shelter – Requires general medical supervision.
[ ] Special Medical Needs Shelter – Requires special medical monitoring and assistance.
[ ] Hospital – Requires acute medical care/isolation precautions.
The information provided on this form shall be used only to attempt to contact you in the event of a
local emergency. This information may be shared with local emergency services and emergency
management personnel.
While it is the goal of the City of Mill Valley to serve its special needs residents in the event of an
emergency, the City 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 City to provide any special or additional services to those individuals providing the
information requested herein or to the public generally.
In the event of an actual emergency response agencies will attempt to provide the necessary
assistance but, because of significantly increased demands on government resources, this cannot
always be assured. To best guarantee personal safety, individuals should take the necessary advance
precautions and follow planning guidance issued by government emergency response agencies.
Should you require special/ambulance transportation and/or hospital facilities, you must make those
arrangements yourself. Personal caregivers should accompany special needs individuals going to a
shelter. The management of nursing, convalescent, retirement and other group facilities are
responsible for the evacuation and sheltering of their own residents.
MAIL TO: Mill Valley Police Department
ATTN: Special Needs Evacuation
1 Hamilton Drive
Mill Valley, CA 94941