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Arkansas Nuclear One - Special Needs Form
This information will remain confidential: however it is needed to help us protect you in an emergency. Please fill out this form, even if you have filled one out before. This information is needed to keep our records current.
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First Name
Your answer
Middle Name
Your answer
Last Name
Your answer
Address
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Address 2
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City
Your answer
State
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Zip Code
Your answer
Phone
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Date of Birth
MM
/
DD
/
YYYY
If you live in a rural area, give directions to your home
Your answer
Please check any of the following which apply to you
Hearing impaired
Sight impaired
I would need special notification in an emergency
I would need a ride in an emergency
I do have a friend, neighbor or relative who could give me a ride in an emergency
The person's name, address and telephone number is:
Your answer
I already have a NOAA Radio
Yes
No
The serial number for the NOAA Radio is:
Your answer
I can hear the weekly siren test
Yes
I am severely handicapped
Yes
A description of my condition is given below:
Your answer
Because of my medical condition, I would prefer to be evacuated to a medical facility rather than the designated reception center
Yes
No
By clicking Submit, I authorize emergency planners to use my information for emergency planning purposes.
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