Special Needs Registry Application

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