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Special Needs Shelter Registration Form - Print and Submit

  1. Personal Information
    Please provide your personal information for registration.
  2. Emergency Contact Information
    Please provide the contact information for a local emergency contact.
  3. Additional Qualifying Information
    Please provide the additional information as it relates to your special or specific needs.
  4. Living Situation
  5. Service Animal
  6. Electric Dependent
  7. Use of Oxygen
  8. Caregiver Information
    If applicable, please provide the following information for your caregiver. *SPECIAL NEEDS CLIENTS MUST BE ACCOMPANIED BY SOMEONE THAT IS CAPABLE
  9. Additional Information
    Additional Information
  10. Leave This Blank: