Emergency Situation Special Needs List Signup

The City of Hartsville Emergency Operations Team is working to compile a list of people with disabilities or special needs that may need assistance in the time of disaster. Please fill out the below form and return it so that we have your information on file in case of an emergency. This may be done on a voluntary basis and is not required by the City of Hartsville.

Special Needs Individual Information

Individual's first name (given name)
Individual's last name (surname)
Individual's phone number. The City of Hartsville may use this to communicate with the individual in the case of an emergency.
(Optional) Individual's email address. The City of Hartsville may use this to communicate with the individual in the case of an emergency.
Physical Address *
Physical Address
City
State/Province
Zip/Postal
Individual's physical location
Please describe the individual needs of the person requesting assistance.

Additional Contact Person Information

Optionally enter information for an additional contact person for the individual above.
What is this contact person's relation to the individual above?
Contact's first name (given name)
Contact's last name (surname)
Contact's phone number. The City of Hartsville may use this to communicate with the contact in the case of an emergency.
Contact's email address. The City of Hartsville may use this to communicate with the contact in the case of an emergency.