Special Needs Citizen's

Special Needs Citizen Request Form

In the event of an evacuation order "Special Needs Citizens" are described as follows:

Anyone who cannot drive and cannot arrange for transportation.

Anyone with a disability or special health care need and requires assistance in getting out of the area,

Anyone who does not have dependable transportation and no safe destination.

If you or someone that you know fits the above description's), PLEASE CALL 2-1-1 as soon as possible to register with the Governor's Division of Emergency Management. It is very important that "Special Needs Citizens" register with 2-1-1 (it's a free call). This will enable Emergency Management official to have a record of you needs and to be better prepared to evacuate you by public transportation to a shelter if the need arises.

DO NOT WAIT FOR AN EVACUATION ORDER TO REGISTER. Even if your health and transportation need are temporary, local governmental agencies need this information now in order to prepare for safe and orderly evacuations.

Special Needs Citizens living in the incorporated city limits of Dickinson call also register by completing the below on line form.

Resident Information: * indicates required information

Email: (If none, leave blank)

*Name:

*Address:

*Phone Number:	Cell Phone:

Physical Condition:


Medication:


Name, age and any special needs of family member's traveling with you:

1)
2)
3)
4)

Pets: Pet Carrier? Yes No

Emergency Contact:

Name:		Phone Number:

Address:		Cell Phone:


Additional Information: You may submit your request electronically by pressing the submit button. You may also print the form and mail or deliver it to the Dickinson Police Department at 4000 Liggio, Dickinson, Texas 77539.