Initial Shelter Dormitory Registration

Shelter Dormitory Registration

Initial registration on behalf of the ARC.
Date & time:

MonthDayYear
Date
Hour Minutes
Shelter location:
Other shelter location:
Primary language:
If other, what language?
If not English, is a family member present who speaks English?
Family name:
E.g., The Smith's
Number of people in the family:
Names and ages of family members:
John Smith age 40, Mary Smith age 38, Johnny Smith age 7, etc.
Primary phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Primary email address:
example@example.com
Home address:

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Information

First & Last Name

Street Address Line 2

Phone NumberState

Email Address
Immediate identified needs of the client of family:
Specific medications, baby needs, religious needs, etc.
Question to ask each client or family:

Is there anything urgent that you or your family need right now, or in the next 6-8 hours? This may include medications, diapers or baby formula, health/religious dietary meals, or other support for a health, mental health, disability, or other condition.

If the client or family identified needs, make a record of the request in this shelter intake form and the request will be passed along to The American Red Cross once on scene.

If a client discloses that they must register with a government agency, please notify the shelter manager or local law enforcement immediately for guidance and make a note in this shelter intake form. Pass along the information to The American Red Cross once on scene.
Does anyone in the household have environmental or food allergies?
If yes, what are the allergies?
Please list each allergy for each person.
Does anyone in the household have any dietary needs for health, religious, or cultural reasons?
If yes, record details for each family member.
Is anyone in the household accompanied by service animal(s)?
Is the service animal required because of a disability?
What work or tasks has the animal been trained to perform?
Any household pets with the client?
Number of pets with the client?
Type of household pet(s) with the client.
E.g., dog, cat, bird
Did the client of family self-disclose any registration requirements with any governmental agencies?
If yes, which governmental agencies?
E.g., Winneshiek County Sheriff's Office
Cot number assigned to client.
Should be Empty: