Florida Irma Address Registration Form - by Hatzalah South Florida

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FILLING THIS FORM OUT DOES NOT GUARANTEE ASSISTANCE, IT IS BEING USED SO WE CAN COLLECT DATA OF WHO IS STAYING IN ORDER TO AID IN OUR RESPONSE EFFORTS.

WE STRONGLY URGE EVERYONE TO LEAVE ANY UNSAFE ZONES AND EVACUATION ZONES, AND GO SOMEPLACE SAFE.

YOU MUST FILL OUT ALL FIELDS - IF THE FIELD DOES NOT APPLY - PLEASE TYPE NONE

This list is being compiled for Hatzalah of South Florida for our post Hurricane response.

For a true MEDICAL EMERGENCY, please call (305) 919-4900.

For Hurricane Irma related issues please call our non-emergency hotline at (786) 410-9566
You can also email us at irma@zakarescue.org

We will do our best to respond as expeditiously as possible.

Email *

First Name *

Last Name *

Address *

Apt #

City *

State

Zip *

Home Phone

Cell Phone

email address

Number of people staying at that location *

Names and Ages of all people staying there. (Please list as follows; John Doe 71, Jane Smith 62 etc.) *

Does anyone there have any medical conditions?

Yes

Clear selection

If Yes, Please describe it to the best of your ability

Does anyone there have any allergies?

Yes

If Yes, please list the allergies

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