Special Needs Online Form

Monaca’s Emergency Operation Plan requires the assessment of the town’s special needs. The purpose of the assessment is to be better able to provide information to emergency response agencies so emergency responders can better plan to serve you should a disaster or other emergency occur.

We also wish to remind you that the first line of defense against the effects of any disaster is personal preparedness. During an emergency, the government and other agencies may not be able to meet your needs. It is important for all citizens to make their own emergency plans and prepare for their own care and safety in an emergency.

Please fill out this online form and submit it to the Emergency Management Agency. This form needs to be updated yearly. After 3 years if we do not receive any type of special needs form, you may be removed from our files.

Preparedness Is Everybody's Job!

Application:

Name:

Address:

City:

State:

Home Phone:

ex: (612) 555-1234

Cell Phone:

ex: (612) 555-1234

Hearing Impaired:

Vision Impaired:

Mobility Impaired:

Will you need Transportation:

Primary Language:

Secondary Language:

Living Situation:

Living Alone

With Spouse

With Children

With Parents

Do you use a:

Do you have Pet(s):

Service Dog:

How many Dog(s):

How many Cat(s):

Other Type of Pets:

How Many?:

Do you permit first responders to enter your home to check on your welfare during an emergency?:

Leave this field blank

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