Health First is proud to partner with Brevard County Emergency Management's program for residents with specific health or medical conditions who need assistance with sheltering in times of an emergency or disaster during an evacuation. In previous years, we mailed a letter to your home asking for you to complete and return the evacuation assistance form. New for this year, we have gone paperless and moved to this online form.

All Health First Medical Equipment customers must complete this form. We appreciate your prompt response.

First Name

Last Name

Phone Number

Home Address

Address

City

State

Zip/Postal Code

I have been offered the opportunity to register for evacuation assistance from the Brevard County Special Needs program. Please select one of the following options:

I do not want assistance with transportation or shelter placement at this time. If I desire assistance in the future, I understand it is my responsibility to contact the Brevard County Office of Emergency Management.

I want to register with Brevard County Emergency Management.

Thank you for your response. Since you have declined emergency evacuation assistance, please select one of the following options:

I will be staying in my home.

I will leave the area.

Thank you for your response. Please provide the following information for where you will be traveling during an emergency evacuation. Enter the full name of your emergency contact below:

Emergency Contact Phone Number

Address

City

State

Zip/Postal Code