Special Needs Registry Application

NOTICE: If you need assistance filling out this application, contact Alexander Emergency Services at 828-632-9336

Date of Application*
Date Format: 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
Phone
Email
Personal Information
Applicant's Full Name*
Prefix First Middle Last
Applicant's Date of Birth*
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address (if different)
Street Address Address Line 2 City State ZIP Code
Name of Subdivision
Main Phone Number
Other Phone Number
Email address (optional)
Marital Status
- Single
- Married
- Divorced
- Widowed
- Separated
Living Situation*
- Live Alone
- With Spouse/Partner
- With Children
- With Parents
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 Information
In-State Emergency Contact*
First Last
Relationship*
Phone
Out-Of-State Emergency Contact
First Last
Relationship
Phone
Medical Provider Information (Fill in all that apply)
Physician Name
Physician Phone
Pharmacy Name
Pharmacy Phone
Home Health Care Agency ( or personal caregiver) Name
Home Health Care Agency ( or personal caregiver) Phone
Respiratory Equipment Provider Name
Respiratory Equipment Provider Phone
Transportation Information
Geographic 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 of
Service Animal
Dogs
Cats
Other 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 Planning
In 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 Information
By 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.
Name
This field is for validation purposes and should be left unchanged.

Alexander County Government
621 Liledoun Road Taylorsville, NC 28681
Phone: (828) 632-9332 | Fax: (828) 632-0059

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Personal Information

Medical Information

Emergency Contact Information

Medical Provider Information (Fill in all that apply)

Transportation Information

Pet Information*

Emergency Planning

Authorization Information