Special Needs

 

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The Galloway Township Ambulance Squad, in conjunction with the Galloway Township Office of Emergency Management, is looking for information on residents that require special attention during emergency situations.  If you or someone you know has a special need that may require our attention during extended power failures, severe weather, etc., please fill out the form below as best as possible.  We will be designing a list of these families so we can assist them when needed.  Thank you.

 

Please provide the following information on the person in need:

Name *

Age

*
Street Address *

Building/Apt #

City *
State *
Zip Code *
Home Phone *
E-mail

Which of the following needs could you need assistance with:*

Dialysis

Oxygen bottle/machine dependent
Pediatric Apnea monitor
Ventilator
Other: (explain below)

*Required

The information provided will not be distributed to any other agencies or organizations.

 

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This page was last updated 01/11/04