EMA

SHELBY COUNTY EMERGENCY ASSISTANCE INFORMATION

In order to better assist Shelby County's disabled citizens or with special needs, please complete this questionnaire. The information will be entered into our confidential Database where EMA Staff can be better equipped to meet your needs.
THE LIFE THIS INFORMATION COULD SAVE--MAY BE YOURS!

SHELBY COUNTY RESIDENTS ONLY

Please provide the following contact information:

Name
Date
Phone
St. Address
Address Cont.
City
State
Province
Zip Code
Age
Next of Kin
Contact of Kin

Select any of the following that apply:

Elderly & Live Alone
Have Transportation
Wheelchair
Walker or Cane
Diabetic
Heart Condition
Dialysis
Impaired Vision
Impaired Hearing
High Blood Pressure
Low Blood Pressure
Oxygen Needed
Elderly & Live Alone
Confined to Bed

ALL INFORMATION IS CONFIDENTIAL AND WILL BE ENTERED INTO THE SHELBY COUNTY EMA DATABASE.  FOR MORE DETAILS CALL THE EMERGENCY MANAGEMENT OFFICE (205) 669.3999

To Submit this completed form, copy and paste into the body of the email when you click here. Email Form