In cooperation with private organizations and community leaders in Palm Beach County, Florida, AccessMyRecords.com has made this service available to its residents. This Special Needs Program has been designed to provide community leaders and emergency responders with information they would need to assist you after a natural disaster. If you are a Palm Beach County, Florida resident and have special needs which may require special attention in the aftermath of a hurricane or other natural disaster, please complete the information below. This information will be made available prior to and after a natural disaster to the organizations and community leaders that have signed up to participate in this program. Please check with your community to see if they have signed on for the program. The program is only available to Palm Beach County residences at this time. If you live outside of Palm Beach County, and would like to participate, please have one of your community leader’s contact us and become part of this program. Call today (561) 443-5508. This program is free to the public.

Organization
*Name (Salutation,First,MI,Last,Suffix)                Mr. Mrs. Miss Ms. --- Jr. Sr. Esq I II III IV V
*Address
Address 2
*City State AL AK AS AZ AR AA AE AP CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI FM MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PA PR RI SC TN TX UT VT VI VA WA WV WI WY SD Zip Code
Community Name
Building / Subdivision
*County Palm Beach
*Phone         (Area code / Phone)
Cell Phone   (Area code / Phone)
Email
Emergency Contact
*Name
*Phone (Area code / Phone)
Cell Phone (Area code / Phone)
Relationship --- Aunt Brother Brother-in-law Daughter Father Father-in-law Grandfather Grandmother Guardian Mother Mother-in-law Other Sister Sister-in-law Son Spouse Uncle
Primary Physician
*Doctor's Name
*Phone   (Area code / Phone)
Special Needs
Do you live alone?	YesNo
Do you use a walker, wheelchair or otherwise need assistance?	YesNo
Do you use an elevator to exit your home, condo or apartment?	YesNo
Does someone prepare meals for you?	YesNo
Do you require a special diet for medical or religious reasons?	YesNo
Please explain.
Do you use oxygen tanks or require other special breathing equipment?	YesNo
Do you use any other type of medical equipment which requires continuous electrical power to function?	YesNo
Please explain.
Do you have a home healthcare aide who regularly comes to your home?	YesNo
Do you take medications that need refrigeration?	YesNo
Please explain.
Do you drive?	YesNo
Are you visually or hearing impaired?	YesNo
Have you filed for an emergency shelter request?	YesNo
Please explain.
Do you have any other needs that are not listed here?	YesNo
Please explain.