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SPECIAL NEEDS AND EVACUATION FORM
Are you a resident of Southold?
Do you have any pets that will need to be sheltered?
Will you need transportation to the shelter?
Supply the name of an individual that could be contacted if necessary.
List any information about your health that will help us understand how to assist you.
List any special equipment that is required for your condition.
While it is the goal of the Town of Southold to serve its special needs residents in the event of an emergency, the Town makes no guarantee or warranty that such services will be provided. Nothing contained in this form is intended to or should be construed as creating any obligation or duty on the part of the Town to provide any special or additional services to those individuals providing the information requested herein, or to the public generally.
This field is not part of the form submission.
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