Special Needs Registry Application NOTICE: If you need assistance filling out this application, contact Alexander Emergency Services at 828-632-9336 Date of Application Choose one:New ApplicationUpdate of Previous ApplicationWho is filling out this form?The ApplicantSomeone else on behalf of the applicantIf 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 BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderMaleFemaleAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of SubdivisionMain Phone NumberOther Phone NumberEmail address (optional) Marital StatusSingleMarriedDivorcedWidowedSeparatedLiving SituationLive AloneWith Spouse/PartnerWith ChildrenWith ParentsPrimary LanguageDo you need the assistance of a translator for English?YesNoFor the Hearing Impaired: Do you use sign language:YesNoTTD/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 ConcentratorVentilatorFor the above 2 choices: Continuous Intermittent Any other required or life-sustaining equipment or medicationMedication 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 RelationshipPhoneOut-Of-State Emergency Contact First Last RelationshipPhoneMedical Provider Information (Fill in all that apply)Physician NamePhysician PhonePharmacy NamePharmacy PhoneHome Health Care Agency ( or personal caregiver) NameHome Health Care Agency ( or personal caregiver) PhoneRespiratory Equipment Provider NameRespiratory 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. This iframe contains the logic required to handle Ajax powered Gravity Forms.