Special Needs Form

If you have a disability that may cause you to need special help in an emergency, please fill out the form below. You can also download the PDF to print out and return to:

Town of Hingham
Department of Emergency Management
339 Main Street, Hingham MA 02043

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If someone you know would require specialized services, urge him or her to complete and return the form. If you have previously filled out a form we ask that you do it again so we can confirm that our current records are up to date. Feel free to call Emergency Management directly if you have any questions or concerns at 781-741-1416. ALL INFORMATION ON THIS FORM IS STRICTLY CONFIDENTIAL.

First Name *

Last Name *

Phone *

Secondary Phone

Email *

Street Address *

Person Completing this Form *

Phone *

Emergency Contact Name *

Emergency Contact Phone *

Check all that apply *

I would arrange my own transportation to a shelter in an emergency.

I would require transportation but could walk a short distance (less than ¼ mile from my home to a bus.

I have limited mobility and would require assistance getting on and off a bus.

I am confined to a wheelchair and would require a wheelchair van.

I would require an ambulance for transportation.

I am deaf.

I use a TTY.

I require electric power for life support equipment.

I have specialized medical or other needs.

Please describe what life support equipment *

Please describe what medical needs *

Captcha *

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Special Needs Form

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