SPECIAL MEDICAL NEEDS PROGRAM
LEE COUNTY EMERGENCY MANAGEMENT
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 7-day hurricane forecast cone.
Personal Information
*
*
*
/
/
*
*
*
*
*
Physical Address
*
    *
    *
    *
    *
    Mailing Address
    *
    *
    *
    *
    Caregiver Information
    *
    *
    *
    *
    *
    Primary Emergency Contact - Local Preferred
    *
    *
    *
    *
    *
    *
    *
    *
    *
    Secondary Emergency Contact
    *
    Provider Information
    Doctor
    Home Health
    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
    Oxygen Assessment
    *
    *
    Additional Medical Information
    *
    Pet Sheltering Needs
    Service Animal Comfort Animal Name Type Breed Weight Carrier/Cage Leash Muzzle
    Representative/Registrant Information
    *
    *
    *
    *

    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.

    It is not necessary to fill out a new application every year.
    Please call (239) 533-0640 once a year to update your application. Thank you!