Access & Functional Needs Registry

2. 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.

   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.

4. 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.

   1. Authorization Granted
5. County*

7. REGISTRANT INFORMATION

9. Last Name*

10. First Name*

11. MI

13. Date of Birth (MM/DD/YYYY)*
    Date of Birth (MM/DD/YYYY)

14. Gender*

    1. Male
    2. Female

15. Weight*

17. Street Address*

18. City*

19. State*

20. Zip*

22. Email Address

23. Primary Phone*

25. Mailing Address (If different)

26. City

27. State

28. Zip

30. Alternate Phone

31. Name of Subdivision, Mobile Home Park, Apartment Building

32. Language*
    -- Select One --ArabicChineseEnglishFrenchGermanItalianKoreanRussianSpanishTagalogVietnamese

34. Living Situation (check one)*

    1. Live Alone
    2. Other (explain below)

    1. With Children

    1. With Parents

    1. With Spouse/Significant Other

36. Living Situation explanation

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

    1. *None
    2. Allergies
    3. Ambulatory with Walker
    4. Ambulatory with Wheelchair
    5. Asthma Emphysema COPD
    6. Bedridden
    7. Contagious Disease
    8. Developmentally Disabled
    9. Dialysis
    10. Gastric Feeding Tube
    11. Hearing Impaired
    12. Insulin Dependent
    13. IV Medication
    14. Medications (List and explain below)
    15. Memory Impaired (Explain below)

    1. Mental Health Condition
    2. Ostomy Care
    3. Oxygen Concentrator/Ventilator Continuous
    4. Oxygen Concentrator/Ventilator Intermittent
    5. Physically Disabled
    6. Portable Oxygen Tank
    7. Refrigeration Needed for Medication
    8. Required for Life-Sustaining Equipment
    9. Seizures
    10. Special Dietary Needs (Explain Below)
    11. Speech Impaired
    12. Suction Machine
    13. Vision Impaired
    14. Other (Explain below)

40. Explain any that have been checked above. List all known diagnoses, medications, etc.

42. DISASTER PLAN*

    1. Stay with family or others
    2. Stay at home
    3. Evacuate to a shelter (no transportation required)
    4. Require transportation to a shelter (specify type needed below)
    5. Will bring a service animal or pet to the shelter
    6. Other (Explain below)

44. Explain

46. EMERGENCY CONTACT INFORMATION

48. Emergency Contact*

49. Work Phone

50. Home Phone

51. Cell Phone

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

55. Physician Name

56. Phone

58. Pharmacy Name

59. Phone

61. Home Health Care Agency (or personal caregiver)

62. Phone

64. Respiratory Equipment Provider (if applicable)

65. Phone

Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field