PO Box 398, Fort Myers, FL 33902-0398
For information call: 239-533-0640
Fax: 239-477-3636
Email: EMspecialneeds@leegov.com

Applications will NOT be processed when Lee County is in the 5-day hurricane forecast cone.
Personal Information

Physical Address

Mailing Address

Caregiver Information

Primary Emergency Contact - Local

Secondary Emergency Contact - Out of Area

Doctor Information

Special Care Assessment

Cognitive Assessment
- please provide stage level of Mild/Early, Moderate, or Late/Advanced for all Cognitive conditions

Mobility Assessment

What help do you require?

Electricity Assessment

Home Health Provider

Additional Medical Information

Pet Sheltering Needs
Service Animal Name Type Breed Weight Carrier/Cage Leash Muzzle Delete

I understand this registration is voluntary and do hereby request to be registered in the Lee County Special Medical Needs Program. The information contained herein is true and correct to the best of my knowledge. I understand there are limitations to the services and levels of care that are available. I hereby grant permission to medical providers, transportation agencies, and others, to provide care and respond to my needs, and for the disclosure of any information necessary to do so. I also grant permission to emergency response agencies to enter my residence for the purpose of emergency search and rescue, and authorize the release of information necessary for these agencies to perform these services. In an effort to ensure the safety of all shelter residents, a background screen will be run on all people evacuating to the Special Medical Needs Shelter, including the caregiver.