Emergency Preparation:

Dear Applicant,

Please complete and return the attached items listed below in order for your name to be considered for placement on the JCOA Database List for the Evacuation of Elderly & Disabled.

• Evacuation Memorandum of Understanding (Word Format - Adobe Acrobat Format)
• Application for Evacuation Assistance (Word Format - Adobe Acrobat Format)
• Demographic Information Face Sheet (Word Format - Adobe Acrobat Format)
• Request for Medical Eligibility Determination for Special Needs Evacuation (Word Format - Adobe Acrobat Format)
• Release of information (Word Format - Adobe Acrobat Format)
• HIPPA agreement (Word Format - Adobe Acrobat Format)

The Jefferson Council on Aging is currently working with the Jefferson Parish Office of Emergency Management in assessing your need for evacuation assistance. Please return this completed packet to:

Jefferson Council on Aging
Attn: Aging & Disability Resource Center - Evacuation
6640 Riverside Drive, Ste. 140
Metairie, LA 70003

Should you have any questions or require additional information, please do not hesitate to contact us at our office number, (504) 888-5880 or for those caregivers living out of state, please call us toll free at (800) 635-1437. For hearing impaired support, please call Louisiana Relay Service: 800-846-5277 (tdd) or 800-947-5277 (voice).

Kindest regards,

LeslieAnn K. Cioti
ADRC Program Manager
Jefferson Council on Aging