�������������������������������� DISASTER SHELTER REGISTRATION
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Family Last Name |
Shelter Location |
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Names |
Age |
Medical Problem |
Referred to Nurse |
Shelter Telephone No.����������������������������� Date of
Arrival |
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Man |
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Pre-disaster Address and
Telephone No. |
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Woman (include maiden name) |
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Children in Home |
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I do do not, authorize release of� the above information concerning my whereabouts or general condition.
Date Left Shelter Time Left Shelter
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Family Member not in Shelter (Location if known) |
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Post
Disaster Address and Telephone Number: |
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Comparable to
American Red Cross
Form 5972 (5-79) Not retained in database, print after completion |
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Notes: (Note any special comments, dietary needs, pets or other remarks that would assist others providing assistance/care for the person(s) that are being sheltered. |
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