Registration Form
Special Matagorda County
Transportation Evacuation Program
Please Print or Type
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Last Name_________________________First___________________MI_________
Date of Birth_________________________________________________________
Veterans Claim Number________________________________________________
Used by the Matagorda County Veterans Service Officer
Address____________________________________________________________
Please give Physical AND Mailing
City____________________________________ZipCode_____________________
Name of Agencies that referred you_______________________________________
Nearest Relative/Friend not living with you_________________________________
Address_____________________________________________________________
City______________________________State___________ZipCode____________
Name of Person who can help you in transit and at the out of town shelter (if
applicable)________________________________________________________
Address__________________________________________________________
City____________________________State________________zip___________
I hereby request to be registered for the Matagorda County Special Transportation Evacuation
Program (STEP) and for evacuation and shelter assistance in the event of an emergency. I
understand and agree that Matagorda County will not be held responsible for any injury to me,or
my responsible party, or for any loss of my property or possessions. I further authorize the release
of my name to individuals as necessary to accomplish this evacuation process.
__________________________________ _________________
Applicant Signature Date
Physicians Name______________________________________________________
Hospital Affiliation_____________________________________________________
Home Health Agency (if applicable)_______________________________________
I need Assistance with:
() Walking to Curb or Road
() Getting on Bus/Van
() Wheelchair Transportation
() Taking Medication
() Other Type of Medical Treatment Required_________________________
Other Impairments:
() Vision () Speech
() Mental () Bladder Control
() Hearing () Other
Language Spoken/Understand_____________________________________________
Are you currently taking medications? () YES () NO
(You will be asked to bring all medications and instructions for use in the event of an evacuation)
Please list any Serious Illnesses_____________________________________________
Please list any Medical Equipment you may require_____________________________
______________________________________________________________________
Please list any Special Instructions__________________________________________________
_______________________________________________________________________________