Bellbrook, OH · Greene County
Special Care and Needs Form
Bellbrook residents with care needs, medical conditions, or transportation needs can use this application to request emergency evacuation and shelter assistance.
What this form is
The Bellbrook Fire Department uses this application to plan for evacuation and shelter assistance during community emergencies. Residents provide personal and emergency contact details, medical and mobility information, equipment needs, and any transportation assistance they may require. The department consults with other health care providers to determine what assistance the program may be able to provide; the form says assistance is offered at no charge but cannot be guaranteed in an extreme emergency.
Who needs it
Bellbrook residents with care needs, medical conditions, or a need for transportation to shelters may complete this application.
How to submit it
Submit the application to the Bellbrook Fire Department at 35 N. West Street, Bellbrook, Ohio 45305. The form lists (937) 848-3272 as the department office phone number.
About notarization
This application is signed without a notary; the signer signs to certify the information, and applicants with an Ohio DNR are asked to bring it to the shelter.
How to submit this form
- 1
Download The Application
Download the Special Care and Needs Form PDF.
- 2
Complete The Form
Print clearly and fill in your personal, contact, medical, mobility, and transportation information.
- 3
Gather Any Relevant Items
If you have an Ohio DNR, bring it with you to the shelter, as the form instructs.
- 4
Submit To The Fire Department
Submit the application to the Bellbrook Fire Department at 35 N. West Street, Bellbrook, Ohio 45305.
Frequently asked questions
- Who should complete the Special Care and Needs Form?
- Bellbrook residents with care needs, medical conditions, or a need for transportation to shelters may complete the application.
- What information does the application ask for?
- It asks for personal and emergency contact details, medical and mobility information, equipment needs, and the type of transportation assistance required.
- Do I need a notary for the Special Care and Needs Form?
- No. The application is signed without a notary. If you have an Ohio DNR, the form says to bring it with you to the shelter.
- How do I submit the Special Care and Needs Form?
- Submit it to the Bellbrook Fire Department at 35 N. West Street, Bellbrook, Ohio 45305. The form lists (937) 848-3272 as the office phone number.