SHELTERS OF LAST RESORT REGISTRA nON/ WAIVER OF LIABILITY FORM
ALL ADULTS (AGED 18
& OVER)
ARE REQUIRED
TO SUBMIT
lD
&
COMPLETE
A REGISTRATION
FORM.
., YES YES Age: Date of Birth: STATE: Driver's License NO State: #& NO NAME: I I toherebylimitation anyoragainst hold and all claims bv nee;lir;ence provision County Relationship:from shelter.orand any be or instrumental County, Baldwin of personal transported to staffing, servicing, or equipping the same nature nearest Number: Name:ANY shelters hospital governmental without evacuation releaseI agree to harmless Baldwin actionsthe or otherwise. access, use, and occupancy or theand the inother of an including entitiesofwhich emergency, amount, designated Commission, AND all shelters, are whether in Date: LIST the use of available shelters includinzthedeath,Baldwin County, youor IInPhone agree to and specially involved caused or PhoneI #:arising out of said Signature: medical case of injury, evacuationcare Iin ALL ALIASES:emergency. loss of any have been, property I Signature:of evacuationevent locateddamaze, DRIVER'S BIRTH: STREET DATE STATE, Provide NUMBER: CHILDREN LICENSE PHONE NUMBER: ONLY for children who are staving in shelter with ou (Alles 17 & Below): - CELL information below CITY, CODE) ZIP (AREA OFADDRESS:CODE: PHONE NUMBER: OF E: LIABILITY: Infectious and/or Contagious Diseases? Current Medications:
1
a Yes a No
The shelter staff has my permission to let callers/visitors know whether I am staying in the shelter.