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SPECIAL NEEDS REGISTRATION FORM - Polk County Florida

SPECIAL NEEDS REGISTRATION FORM - Polk County Florida 2026

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The document is a registration form for individuals with special needs in Polk County, Florida, intended for use during emergency situations. It collects personal, medical, and provider information to ensure appropriate assistance and care for those with disabilities or medical conditions.

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Click ‘Get Form’ to open the SPECIAL NEEDS REGISTRATION FORM in the editor.
Begin by filling out the 'Individual Information' section. Enter your last name, first name, middle initial, date of birth, and gender. Provide primary and alternate phone numbers, and indicate if you are a full-time resident.
Complete your address details including street number, street name, city, and zip code. If applicable, include your mailing address and specify if you live in a mobile home.
In the 'Medical Information' section, answer questions regarding your health conditions such as diabetes or heart disease. List any medical equipment that requires electricity and medications you are currently taking.
Fill out the 'Provider Information' with details about your home health agency, physician, and any medical supply companies you use.
Indicate any special circumstances like being oxygen dependent or needing assistance with medication in the respective sections.
Finally, complete the 'Transportation' section by indicating if transportation is required and how many steps lead to your front door.

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Versions	Form popularity	Fillable & printable
2019	4.2 Satisfied (45 Votes)
2015	3.9 Satisfied (24 Votes)

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What are the rules of a shelter?

You are responsible for your belongings and may not buy, trade and/or sell your belongings with others. Weapons are not allowed in shelter and nothing may be used as a weapon. Possession, use, or distribution of alcohol or illegal drugs is not allowed within the shelter.

What is considered a special needs shelter in Florida?

A special needs shelter is a temporary emergency facility capable of providing care to residents whose medical condition may require the use of electrical equipment, oxygen, dialysis, or individuals with physical, cognitive, or medical conditions that may require assistance from medical professionals.

What is the phone number for Polk County Florida?

Board of County Commissioners Administration Office Our contact phone numbers include: Main Switchboard: (863) 534-6000. Telephone Device for the Deaf (TDD): (863) 534-7777. Toll Free: (800) 780-5346.

What are the guidelines for special needs shelters in Florida?

The basic eligibility criteria you would need to meet to stay in a special needs shelter: 1) You are a person with special medical needs 2) Your care exceeds the basic first aid provided at general population shelters 3) Your impairments or disabilities are medically stable and do not exceed the capacity, staffing and

What is the Florida special needs registry?

The Florida Division of Emergency Management, in coordination with each local emergency management agency in the state, developed a registry to allow residents with special needs to register with their local emergency management agency to receive assistance during a disaster.

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What does a special needs shelter include?

A special needs shelter provides refuge during emergencies for residents who need limited medical assistance, oxygen, or electrical support but do not require hospitalization. These shelters are staffed with medical personnel and are equipped to provide basic care and monitoring.

How do shelters work in Florida?

When disasters occur, the state provides safe refuge in temporary emergency shelters often located in schools, office buildings, tents or other facilities. General population shelters are well stocked with basic necessities for survival including food, water and a warm place to sleep.

What is the special needs shelter in Lee County?

The Lee County Special Needs Program is open to all Lee County residents with medical needs that require electricity at no cost. It provides shelter for those who live in a home or area that is not safe from storm surge or wind and have no other place to go.

SPECIAL NEEDS REGISTRATION FORM - Polk County Florida 2026

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