Oxygen
Parish of Ascension
Medical Special Needs Registry
OFFICE OF HOMELAND SECURITY
AND
EMERGENCY PREPAREDNESS
Kenny Matassa
Parish President

Richard A. Webre
Director
Oxygen2Ascension is a joint venture between the Office of Homeland Security and Emergency Preparedness (OEP) and the Ascension Chamber of Commerce (Leadership Class of 2009). The Oxygen2Ascension program is designed to supply life sustaining oxygen to parish residents in need, during Declared State of Emergencies. A mobile bank of compressed oxygen cylinders will be placed in strategic areas around the parish. Residents will be able to bring their oxygen cylinders to be refilled free of charge.
Name:
(Last)

(First)

(Middle)
Address:
(Street Address)

(Apartment Number)
City: State: ZIP:
Ascension Parish Residents Only
Home Telephone:
Email Address:
Date of Birth:
Male Female
Do you require oxygen on a daily basis? If yes how much?
Emergency Contact:
(Name)

(Cell Phone)
Are you Homebound? YES NO
Do you require transportation assistance
during evacuation emergencies?
YES NO
Which of the following apply?
Deaf/Hard of Hearing  Blind/Visually Impaired  Uses Wheelchair Uses Crutches/Walker/Braces
Confined to Bed Mental Retardation Cardiac Condition Mental Illness
 Epilepsy Chronically Obese Speech Impairment Other:
Person responsible for filling out this form
Name:  
(Last)

(First)
Address:
(Street Address)

(Apartment Number)
City: State: ZIP:   
Telephone:
This is: Voice TTY Both
Disclaimer: Ascension Parish will not use information submitted on this site for solicitation purposes and does not share private information with anyone.