Columbia County PA Request for Special Assistance
If you have a disability or special/functional need that will require assistance during an emergency evacuation, please fill out and return this form. Provisions have been made to provide transportation to those who need it, but it is very important those needs are identified before the emergency. Local authorities will keep this information confidential. This form should be completed annually. It is very important to submit a form every year so we have the most updated information about your needs.

Any questions please contact The Columbia County Emergency Management Office 570-389-5720.
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Person Needing Assistance Name *
Person Needing Assistance Full Address *
Person Needing Assistance Municipality *
Person Needing Assistance County *
Person Needing Assistance Home Phone Number *
Person Needing Assistance Mobile/Secondary Phone Number
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