Special Needs Registry

Name: ,

Age:
Physical Address:
Mailing Address:
Telephone #: TTD/TTY?

Telephone #:

Primary Language: Social Security#:
Emergency Contact Person:
Address:
Telephone #:

Relationship:


Special Needs:

 

 

Self-Ambulatory   Wheelchair User
Ambulatory with Assistance Bedridden
Feeding Tube I.V. Fluids
Insulin Life Support
Suction Unit Dialysis
Special Diet Subject's Weight
Diet Type Hearing Impaired
Sight Impaired Speech Impaired
Contagious Disease    
Specify Other Disabilities:

Oxygen Dependent

If Yes:

Do you rely on electricity
Battery back-up
Home Generator
Cylinders
Spares Available

Oxygen Provider:

Hours Daily Portable Tank Concentrator

 

Care:

Require 24 Hour Care Giver?    
Home Health Care Provider Provider #:
Primary Physician Phone #
Pharmacist Phone #

In case of a disaster do you plan to: (Select One)

Stay with family or others. Please give the name, address, telephone number and relationship of the person you plan to stay with during emergencies.

Stay at home (if the situation is safe to do so).
Evacuate to a shelter

Can you get to an evacuation shelter on your own?

If no, check the kind of transportation needed:

Standard Vehicle (bus, car, etc.)

Ambulance
Wheelchair Equipped

Will a caregiver accompany you to the evacuation shelter?

Do you have an Assistance Dog ( such as a guide dog)

If yes, describe

I will need the following accommodations for an assistance dog*


* Note: Individuals are responsible for caring for the needs of an assistance dog, including bringing food and other essential needs to a shelter

Call 335-4444 if you have any questions or if you need any assistance in completing this form.

If at any time your conditions changes or for any reason this registrant no longer needs to be listed on the Pasquotank-Camden Special Needs Registry, please contact the Pasquotank-Camden-Elizabeth City Emergency Management Office at 335-4444.


I certify that the above information is correct. I understand that I am responsible for all expenses associated with medical evacuation and shelter at a hospital, nursing facility or for any specialized equipment needed in a special needs shelter.

I hereby grant permission to Pasquotank-Camden-Elizabeth City Emergency Management Agency to release this information to other emergency response or human service agencies or officials. I also give local law enforcement and/or medical personnel permission to enter my home in case of an emergency.