Special Needs Registry Application NOTICE: If you need assistance filling out this application, contact Alexander Emergency Services at 828-632-9336 "*" indicates required fields Date of Application* MM slash DD slash YYYY Choose one:* New Application Update of Previous Application Who is filling out this form?* The Applicant Someone else on behalf of the applicant If you are filling out this form for someone else or on behalf of the applicant, please fill in your contact info* First Last PhoneEmail Personal InformationApplicant's Full Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Applicant's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Subdivision Main Phone NumberOther Phone NumberEmail address (optional) Marital Status Single Married Divorced Widowed Separated Living Situation* Live Alone With Spouse/Partner With Children With Parents Other Primary Language* Do you need the assistance of a translator for English? Yes No For the Hearing Impaired: Do you use sign language? Yes No TTD/TTY #: Medical Information(Check all that apply to your medical condition) Hearing/impaired Visually Impaired Speech impaired Memory Impaired Mentally Impaired Special Behavioral Concerns Bedridden Use Wheelchair Walker Cane Requires 24 hr Caregiver Bariatric needs/ weight excess of 400 lbs Ongoing contagious condition (specify below) Allergies (specify below) Seizures DNR Living Will Special Dietary needs* (specify below) *If you require a special diet, be prepared to bring with you the appropriate foods. IV Medication Injections Refrigeration for Medication Insulin Dependent Wound Care Incontinence Supplies Ostomy Care Suction G-tube N-G tube Dialysis Sleep Apnea Machine Pacemaker Defibrillator Portable Oxygen Tank Any additional information related to the medical conditions listed above.Either of these? Oxygen Concentrator Ventilator For the above 2 choices: Continuous Intermittent Any other required or life-sustaining equipment or medication Medication Management: You are strongly encouraged to prepare an emergency kit with necessary medical supplies and to keep in that kit an updated list of necessary medications. For information on preparing an emergency kit, plese visit www.ready.gov or www.RedCross.org. Emergency Contact InformationIn-State Emergency Contact* First Last Relationship* PhoneOut-Of-State Emergency Contact First Last Relationship PhoneMedical Provider Information (Fill in all that apply)Physician Name Physician PhonePharmacy Name Pharmacy PhoneHome Health Care Agency ( or personal caregiver) Name Home Health Care Agency ( or personal caregiver) PhoneRespiratory Equipment Provider Name Respiratory Equipment Provider PhoneTransportation InformationGeographic Location Flood Plain Isolated/Difficult to Reach Mobile Home Can you, a family member or friend provide you with transportation to a shelter in an emergency? Yes No If you need assistance with transportation, check one of the following Able to Ride in Car Able to Ride in Bus/Taxi Van with Wheelchair Lift Ambulance Required Pet Information*Do you have pets that would require special attention if you were asked to evacuate your home? If so indicate the number ofService AnimalDogsCatsOther Pets (Describe other) *Pets may not be able to accompany you to the shelter. Individuals are responsible for caring for the needs of an assistance animal, including bringing food and other essential needs to the shelter. Service animals are allowed in shelters but must provide proof of current rabies vaccine.Emergency PlanningIn case of an emergency, do you plan to: Stay with family or others? Stay at home? Evacuate to an appropriate facility, independently? Evacuate to an appropriate facility with caregiver Authorization InformationBy submitting this form I agree or my legal guardian requests that my personal and medical information be added to the Alexander County Special Needs Registry. In the event of an emergency or disaster I hereby authorize the exchange of information between Alexander County, and the local fire department, rescue squad, or law enforcement agency and the individuals and agencies listed on this form. I grant emergency responders permission to enter my home following an emergency event or disaster situation, if necessary, to assure my safety and welfare and for the purposes of evaluating my needs.PhoneThis field is for validation purposes and should be left unchanged.