Register for Hurricane Evacuation Assistance Application

REGISTER FOR HURRICANE EVACUATION ASSISTANCE

In order to assist you with transportation needs in the event of an evacuation order, please fill out the following form as completely as possible.

If you would rather fill out this information on a paper version, you may print a PDF version of this application by clicking here. Return this form with your water bill payment, drop it off in the night deposit, or bring it into Gretna City Hall at 740 2nd Street (at the corner of Huey P. Long Ave and 2nd Street). Business hours are Monday - Friday, 8:00 AM to 4:30 PM. You may also visit Gretna City Hall to fill out a form in person.

NOTE: Regardless of whether or not you believe that we have your information on file, please fill out this form again so that we may update your information. You must re-register every year.

Name*

Street Address (incorporated Gretna only)*

Primary Phone Number*

Alternate Phone Number

Email Address*

In the event of an evacuation, how many in the household will need transportation?*

Please explain any special needs in your household

MEDICAL / MOBILITY SPECIAL NEEDS

A personal care assistant will travel with me.*

Yes
No

What portable equipment will you bring? (Please check all that apply)

If other portable equipment, please specify

What will you bring for mobility? (Please check all that apply)

If other mobility item, please specify

VOLUNTARY SUBMISSION NOTICE

I am submitting this information voluntarily and understand that the information provided will be used for providing transportation in the event a declared emergency evacuation is called, and I am asked to leave my home for safety reasons.

By typing my full name here I confirm that I have read and understand the voluntary submission notice*