DISASTER SHELTER REGISTRATION
(click
here if you prefer a MS Word version of the
form below)
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Family Last Name |
Shelter Location |
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Names |
Age |
Medical Problem |
Referred to Nurse |
Shelter Telephone No. Date of
Arrival |
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Man |
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Pre-disaster Address and
Telephone No. |
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Woman (include maiden name) |
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|
|
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Children in Home |
I
do
do not, authorize release of
the above information concerning my whereabouts or general condition.
Date
Left Shelter
Time Left Shelter
|
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Family Member not in
Shelter (Location if known) |
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Post
Disaster Address and Telephone Number: |
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