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.
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. Evacuate to a shelter (no transportation required)
    2. Require transportation to a shelter (specify type needed below)
    3. Stay at home
    4. Stay with family or others
    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:


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

    This field is not part of the form submission.

69. Submit Submit and Print

* indicates a required field