Emergency Evacuation Assistance Registration

Print
Press Enter to show all options, press Tab go to next option
Please correct the field(s) marked in red below:

The Office of Emergency Management

Emergency Evacuation Assistance Registration


To better meet the emergency preparedness needs if the county, the Yuma County Office of Emergency Management (OEM) developed a pre-registration process for county citizens who may require assistance during an emergency evacuation. The Emergency Evacuation Assistance Registry is designed for people with special needs, such as mobility issues, inability to drive, or sight or hearing problems, that may hinder their ability to evacuate during an emergency situation.
The OEM will reference the pre-registration information to assist emergency personnel in determining the transportation needs of these individuals during emergencies requiring evacuation, such as wildfires, flooding or hazardous material spills, such as gas leaks.

The Emergency Management Office is solely responsible for maintain and safeguarding the confidentiality of this data. By providing this information, you are authorizing the information contained herein to be released to the county's OEM office and emergency response personnel.

 

Registration does not guarantee availability of transportation.


1

First and Last Name:

2
Date of Birth: (MM/DD/YYYY):
3

Primary Phone Number:

4

Alternate Phone Number:

5
Street Address for Evacuation Assistance:
6

Apartment Number: (If Applicable)

7

Complex or Subdivision Name:

8

City:

9
Special Directions to Evacuation Address:
10
Email Address:
11
What Types of Assistance Will You Require? (Check each that apply)
 *
What Types of Assistance Will You Require? (Check each that apply)
12
Do you require special transportation vehicle or requirements? (i.e., wheelchair lift vans, ambulance, etc)
 *
Do you require special transportation vehicle or requirements? (i.e., wheelchair lift vans, ambulance, etc)
13
Please list any medical equipment that you will need to bring with you:
Please list any medical equipment that you will need to bring with you:
14
Emergency Contact Name:
15
Emergency Contact Phone:
16
Do you have pets to evacuate?
 *
Do you have pets to evacuate?
17
Please indicate your primary language:
18
Are you also fluent in spoken English?
 *
Are you also fluent in spoken English?
19
Have you made plans for alternative shelter in the event of an emergency evacuation?
 *
Have you made plans for alternative shelter in the event of an emergency evacuation?
If you have not made emergency plans or would like additional information, please visit the Office of Emergency Management to learn more about preparing for an emergency.
20
Additional Comments:
    CAPTCHA
    Change the CAPTCHA codeSpeak the CAPTCHA code
     

    Online Help Center

    • Leave Us a Message
    • Submit a Service Request
    • County Directory