Sleeping accommodations    Accessible cots Crib Other ______________________________________ Access to transportation:    Wheelchair accessible vehicle Individualized assistance Transportation of equipment required Assistance with activities of daily living:       Eating Taking medication Dressing/undressing Walking Stabilization Climb Stairs     Transferring to/from wheelchair or other mobility aid Bathing Toileting Communicating Check all that apply:    IV medication Dialysis Insulin Dependent Diabetes    Requires medical observation Open wounds/decubitus Assistance with Meds Including Insulin    Respirator dependent Hypertension Immune deficiency    Chronic respiratory condition Incontinence Unstable  Oxygen required (flow rate L/M _________________)  Dependent on power operating equipment to sustain life (Please specify____________________________________)  Medical Diagnosis: (i.e. insulin dependent diabetes, dialysis, hypertension, Chronic respiratory Conditions) Requires licensed care provider to perform the following: ___________________________________________________   Terminal Contagious condition, ex. Flu-like symptoms (specify___________________________)  Ongoing treatment Please (Please add info on any of the previous conditions)  Other
Sleeping accommodations  Accessible cots  Crib  Other ______________________________________ Access to transportation:  Wheelchair accessible vehicle  Individualized assistance  Transportation of equipment required Assistance with activities of daily living:  Eating  Taking medication  Dressing/undressing  Walking  Stabilization  Climb Stairs  Transferring to/from wheelchair or other mobility aid  Bathing  Toileting  Communicating Check all that apply:  IV medication  Dialysis  Insulin Dependent Diabetes  Requires medical observation  Open wounds/decubitus  Assistance with Meds Including Insulin  Respirator dependent  Hypertension  Immune deficiency  Chronic respiratory condition  Incontinence  Unstable  Oxygen required (flow rate L/M _________________)  Dependent on power operating equipment to sustain life (Please specify____________________________________)  Medical Diagnosis: (i.e. insulin dependent diabetes, dialysis, hypertension, Chronic respiratory Conditions) Requires licensed care provider to perform the following: ___________________________________________________  Terminal  Contagious condition, ex. Flu-like symptoms (specify___________________________)  Ongoing treatment Please (Please add info on any of the previous conditions)  Other
Hurricane-Registry-Application-2018.docx