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:
Geismar
Gonzales
Sorrento
St. Amant
Prairieville
Donaldsonville
Darrow
State:
ZIP:
*
Invalid Zip Code
Ascension Parish Residents Only
Home Telephone:
*
XXX-XXX-XXXX
Email Address:
Date of Birth:
*
MM/DD/YYYY
Male
Female
Do you require oxygen on a daily basis?
YES
NO
If yes how much?
Emergency Contact:
*
(Name)
*
(Cell Phone)
XXX-XXX-XXXX
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:
Geismar
Gonzales
Sorrento
St. Amant
Prairieville
Donaldsonville
Darrow
State:
ZIP:
Invalid Zip Code
Telephone:
XXX-XXX-XXXX
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.