2. SOUTHOLD EMERGENCY MANAGEMENT
   SPECIAL NEEDS AND EVACUATION FORM
4. Last Name*
5. First Name*
6. Middle Initial
8. Date of Birth*
9. Telephone Number*
10. Cell Phone Number
12. Local Address 1*
14. Local Address 2
16. Hamlet*
17. State
18. Zip
20. Local Resident*

    1. Yes
    2. No

    Are you a resident of Southold?
21. Pets

    1. Yes
    2. No

    Do you have any pets that will need to be sheltered?
22. Transportation Required*

    1. Yes
    2. No

    Will you need transportation to the shelter?
24. Emergency Contact Number
    Supply the name of an individual that could be contacted if necessary.
26. Last Name
27. First Name
29. Address1
31. Address2
33. City
34. State
35. Zip
37. Relationship
38. Telephone Number
39. Cell Phone Number
41. Condition / Disability
    List any information about your health that will help us understand how to assist you.
43. Special Equipment
    List any special equipment that is required for your condition.
45. Physician's Name
46. Physician's Telephone Number
48. Additional Comments
50. Legal Disclaimer
    While it is the goal of the Town of Southold to serve its special needs residents in the event of an emergency, the Town 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 Town to provide any special or additional services to those individuals providing the information requested herein, or to the public generally.
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52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit Submit and Print

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