Your Name: 

Physical Address:    City:  Aeneas Valley Brewster Conconully Carlton Coulee Dam Elmer City Loomis Malott Nespelem Mazama Omak Okanogan Oroville Pateros Riverside Tonasket Twisp Winthrop

Mailing Address: 

Telephone Number:     Cell Number: 

Email Address:     DOB: 

Gender:  Male Female    Primary Language:    TDD/TTY?  Yes   

**********  Residence Information**********

Type of Residence:   Private home     Apartment/Condo/Duplex   Mobile Home    Retirement Home   

Name of Complex/Subdivision/Mobile Home Park:

Do you have pets?    Yes     If yes, do you have arrangements for them in an emergency? Yes   No  

     (Please be advised, pets cannot go to the shelter with you unless they are a service animal.)

Does someone in your home use a life-support machine that relies directly on electrical power?    Yes     

     Unplanned outage are usually caused by an emergency situation, we urge you to have some type of backup equipment.

Does your home rely on electricity for your only source of heating?     Yes      

Are you a full-time resident?   No    If no, how many months do you live in the area: 

**********Evacuation Information/Notification**********

If you evacuate, you plan to go to:  Family      Friend    Shelter

Local Emergency Contact: 

Name/Relationship: 

Address: 

Phone/Cell/Email: 

Out of County Emergency Contact:

Name/Relationship:

Address:  

Phone/Cell/Email:

Will you require evacuation assistance?  Yes    If yes, what type of transportation will you need? 

     Standard Vehicle    Wheelchair Capable    Ambulance      Stretcher

Do you:  care for yourself or regularly have assistance from a caregiver

     Name of Caregiver:

     Telephone:  

     Address: 

     If going to a shelter, will your caregiver accompany you to the shelter?   Yes   No

                             **********Medical Information**********

Which illnesses do you take medication for?

      Heart problems            Blood pressure                            Breathing Problems               Pain

        Stroke                             Diabetes/Insulin dependent?     Seizures/Convulsions           Alzheimer’s/Dementia

      Other (Identify)   

Hearing Impaired/Deaf:  Yes   No

Legally Blind/Sight Impaired/Service Dog:  Yes         Identify applicable condition:

Medical dependency on electricity (electrically powered equipment).  Yes                   

      Dialysis   Nebulizer  Ventilator    Oxygen and breathing equipment.  

        Require oxygen hrs a day; liter flow:                 Oxygen provider: 

        Do you have an oxygen machine concentrator  Yes   or a portable tanks?  Yes   

         Intravenous and feeding tube equipment

Mobility Disability(ies): 

     Walk with cane/walker  Yes      Use wheelchair  Yes ; (have manual back-up wheel chair? Yes )

     Bedridden  Yes                                                           

Other limitations:

Speech Impaired: Yes   

Name of Physician: 

Telephone:

TERMS/AGREEMENT:

I understand that in the event of an actual emergency, response agencies will attempt to provide the necessary assistance, but because of significantly increased demands on county government resources this cannot always be assured.  To best guarantee your personal safety, individuals should take the necessary advance precautions and follow planning guidance issued by government emergency response agencies.  (Initial)

The information contained herein is true and correct to the best of my knowledge. I understand that assistance will be provided only for the duration of the emergency, and that alternative arrangements should be made in advance in case I am not able to return to my home. (Initial)

I understand that I am responsible for assisting in the provision of any prescription medications, oxygen supplies, medical equipment, and special dietary items that I may require during the emergency. (Initial)

I also understand that I will be responsible for any charges and costs associated with hospital and other medical facility care or medical transportation. (Initial)

I grant permission to medical providers and transportation agencies and others as necessary to provide care and disclose any information necessary to respond to my needs.  (Initial)

I hereby grant permission for the release of this information to emergency response agencies and pre-authorize these agencies to enter my residence for the purpose of emergency search and rescue.  (Initial)

I understand my participation in this registry is voluntary and all information maintained will be strictly confidential, used only for emergency purposes and hereby request registration in the Special Needs Registry Program.  (Initial)

I agree to keep my registration information current.  I will inform Okanogan County Emergency Management (509) 422-7206 of any changes that may occur and affect this registration record.  (Initial)

FOR METHOW VALLEY RESIDENCE ONLY:  I understand that my information will also be maintained at Aero Methow Rescue, Twisp Police Department, and the Winthrop Marshall's Office. (Initial)