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2. Name of Person Needing Assistance*
3. Address*
5. Township*
6. Date of Birth*
   Date of Birth
8. Home/Cell Phone Number*
9. Additional Phone Number
13. Type of Assistance Required*

    1. Oxygen
    2. Mental Impairment
    3. Sight Impaired
    4. Electricity Dependent (ventilator/BIPAP/external heart pump)

    1. Hearing Impaired
    2. Confined to Bed
    3. Use of wheelchair/walker/cane
15. Evacuation Transportation Necessity*

    1. Auto

    1. Wheelchair

    1. Wheelchair/lift van

    1. Ambulance
19. Emergency Contacts
    List your emergency contacts below.
21. Name
22. Phone
24. Address
25. Cell Phone
27. Name
28. Phone
30. Address
31. Cell Phone
35. Release of Information
    I hereby authorize Roscommon County Central dispatch to release all or part of such information as may be necessary to ensure my safety, treatment, and well being in the event of a medical disaster or public emergency.
37. Signature*
38. Date*
    Date
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field