LAST: ______________________ FIRST: ________________ DOB: __/__/__ GENDER: _____
PHYSICAL ADDRESS: ______________________________________________________________
(Street, Apt. Number) (City)
MAILING ADDRESS: _______________________________________________________________
TELEPHONE: (509) _________________________________________ TDD/TTY? Yes
E-MAIL ADDRESS: ______________________________________________________
PRIMARY LANGUAGE: ______________________
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 your home rely on electricity for your only source of heating? Yes
Are you a full-time resident? No ; If no, identify months that you live in the area:
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
Which illnesses do you take medication for?
Heart problems Blood pressure
Stroke Diabetes/Insulin dependent?
Breathing Problems Pain
Seizures/Convulsions Alzheimer’s/Dementia
Other
Hearing Impaired/Deaf: Yes
Legally Blind/Sight Impaired/Service Dog Yes (Circle 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 or portable tanks? Yes
(Circle One).
Intravenous and feeding tube equipment
Mobility Disability(ies):
Walk with cane/walker Yes
Use wheelchair Yes ; do you have a manual back-up wheelchair? Yes
Bedridden Yes No
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 understand that my information will also be maintained at the local Emergency Medical Services and Police Department (if applicable). ______ (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)
Registrant Signature: ____________________________________ Date: __________
Caregiver: _____________________________________________ Date: __________
(If Registrant is unable to sign)
Relationship to Registrant (if any): _________________________________
Please mail the completed form to:
Okanogan County Sheriff’s Office Emergency Management
ATTN: Special Needs Registry
123 5th Ave N., Room 200
Okanogan, WA 98840