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Access & Functional Needs Registry

  1. 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.

  2. 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.

  3. REGISTRANT INFORMATION

  4. Gender*

  5. Living Situation (check one)*

  6. MEDICAL HISTORY (CHECK AND COMPLETE ALL THAT APPLY TO THE REGISTRANT'S CONDITION)*

  7. DISASTER PLAN*

  8. EMERGENCY CONTACT INFORMATION

  9. MEDICAL PROVIDER INFORMATION (FILL IN ALL THAT APPLY)

  10. Leave This Blank:

  11. This field is not part of the form submission.