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Special Needs Evacuation Program

Special Needs Evacuation Form

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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 submit it online to enroll in the program. The Mill Valley Police 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.

Please Note: * All sections are required. Do not leave any sections blank. If a section does not apply to you, type "N/A" in the field provided.

* * * Please read through the entire form before beginning to fill it out. You will not be able to save the data and come back to it later. Be sure to have all the information needed on-hand before you begin. There are 3 pages, and 41 questions total.

Section 1 - Personal Enrollment Data

1. Last name:

2. First name:

3. Middle name:

4. Gender:
5. Street address:
Street number
(example "123")
Street name
(example "Elm Street")
6. Mailing address:
(If different from your street address. If the same, please type "same")
7. Home or land line phone number:

8. Mobile phone number:

9. Date of birth:
10. Do you speak English?
11. Residence type:

12. Living Situation:

13. Emergency Contacts

Name of contact in your home:

14. Name of local contact:

15. Relationship of local contact:

16. Phone number of local contact:

17. Name of non-local contact:

18. Relationship of non-local contact:

19. Phone number of non-local contact:

20. Person completing this form:
(If different from above. If same, please type "same")
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