By filling out this form I give my authorization for the medical information contained herein to be released to the Broward municipalities, emergency management agencies, hospitals, and private social service agencies for the purpose of evaluating my needs and providing emergency transportation and sheltering. Records relating to registration of disabled citizens are exempt from the provisions of F.S. 119.07(1), Public Records Law. The information contained here will be kept confidential.

E-mail addresses are public records under Florida law and are not exempt from public-records requirements. If you do not want your e-mail address to be subject to being released pursuant to a public-records request, do not send electronic mail to this entity and do not enter an email address in the database. The email address field is optional. If you have any questions, please call the Broward County Call Center at 954-831-4000, the TTY phone number is 954-831-3940.

Please remember that registration into this database is not a guarantee that you will be provided services or be placed on a priority list for emergency response.