�������������������������������� DISASTER SHELTER REGISTRATION

Family Last Name

Shelter Location



Medical Problem

Referred to Nurse

Shelter Telephone No.����������������������������� Date of Arrival





Pre-disaster Address and Telephone No.

 Woman (include maiden name) 




Children in Home





I do do not, authorize release ofthe above information concerning my whereabouts or general condition. 

/ Printed Name

Date Left Shelter

Time Left Shelter


Family Member not in Shelter (Location if known)



Post Disaster Address and Telephone Number:

Comparable to American Red Cross Form 5972 (5-79)
Not retained in database, print after completion

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.
Not retained in database, print after completion