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Access & Functional Needs Registry
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The purpose of the Rowan County Access and Functional Needs Registry is to provide emergency responders with important information from individuals that may require assistance during an emergency, (e.g. hurricane, flood, blizzard, power-outage and/or disease outbreak). This program is voluntary and individuals on the registry may decide whether or not to accept assistance. Completion of this form in no way ensures that the individual completing this form will receive immediate or preferential treatment in an emergency. Individuals should maintain a personal emergency plan.
Release Authorization
*
By clicking the below authorization box, I/legal guardian agree that my name be added to the Rowan County Access and Functional Needs Registry. In the event of an emergency I hereby authorize the exchange of information between Rowan County Emergency Services, NC Emergency Management 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.
Authorization Granted
County
*
Registrant Information
Last Name
*
First Name
*
MI
Date of Birth (MM/DD/YYYY)
*
Date of Birth (MM/DD/YYYY)
Gender
*
Male
Female
Weight
*
Street Address
*
City
*
State
*
Zip
*
Email Address
Primary Phone
*
Mailing Address (If different)
City
State
Zip
Alternate Phone
Name of Subdivision, Mobile Home Park, Apartment Building
Language
*
-- Select One --
Arabic
Chinese
English
French
German
Italian
Korean
Russian
Spanish
Tagalog
Vietnamese
Living Situation (check one)
*
Live Alone
Other (explain below)
With Children
With Parents
With Spouse/Significant Other
Living Situation explanation
Medical History (check and complete all that apply to the registrant's condition)
*
*None
Allergies
Ambulatory with Walker
Ambulatory with Wheelchair
Asthma Emphysema COPD
Bedridden
Contagious Disease
Developmentally Disabled
Dialysis
Gastric Feeding Tube
Hearing Impaired
Insulin Dependent
IV Medication
Medications (List and explain below)
Memory Impaired (Explain below)
Mental Health Condition
Ostomy Care
Oxygen Concentrator/Ventilator Continuous
Oxygen Concentrator/Ventilator Intermittent
Physically Disabled
Portable Oxygen Tank
Refrigeration Needed for Medication
Required for Life-Sustaining Equipment
Seizures
Special Dietary Needs (Explain Below)
Speech Impaired
Suction Machine
Vision Impaired
Other (Explain below)
Explain any that have been checked above. List all known diagnoses, medications, etc.
Disaster Plan
*
Evacuate to a shelter (no transportation required)
Require transportation to a shelter (specify type needed below)
Stay at home
Stay with family or others
Will bring a service animal or pet to the shelter
Other (Explain below)
Explain
Emergency Contact Information
Emergency Contact
*
Work Phone
Home Phone
Cell Phone
Medical Provider Information (fill in all that apply)
Physician Name
Phone
Pharmacy Name
Phone
Home Health Care Agency (or personal caregiver)
Phone
Respiratory Equipment Provider (if applicable)
Phone
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Email address
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