Special Needs Registry Application
 

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For the Deaf & Hard of Hearing: Do you use sign language:

Living Situation (Check One): *




 
Medical Information (Check those that apply to your medical condition).






















Emergency Contact Information
 
Emergency Contact Information
 
Max 1000 Characters
 
 
 
 
Can You, a family member or friend provide you with Transportation to a shelter in an emergency?: *

 
If you need assistance with transportation, check one of the following:



Do you have pets that would require special attention if you were asked to evacuate your home?



In case of an emergency, do you plan to? (Check the one that applies) *



 
Shelter Information
Authorize Information Agreement *
 

 




 Rockingham County North Carolina
Contact Us
Rockingham County Government
371 NC Hwy 65
Reidsville NC 27320
Phone: 336.342.8100
Fax: 336.342.8105
 
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