EMERGENCY
DATA - Special Needs
Registry Form
Craven County
Department of Social Services
Name
__________________________________ Please check all special needs you may
have:
Physical Address _________________________ ___ legally blind
________________________________________ ___ deaf
Mailing Address __________________________ ___ terminally ill
_________________________________________ ___ contagious disease
Phone Number:____________________________ ___ bedridden
TTD/TTY: ______________________________ ___ ambulatory with
assistance (walker, cane,
Date of Birth: ______________Age ______
wheelchair, etc.)
Physician's Name: __________________________ ___ dialysis (3 or more
times per week)
Phone: _________________________________ ___ IV
fluids or medication
Home Health Care Provider: _________________ ___ insulin dependent
(need assistance)
Phone: _________________________________ ___
feeding tube
Where do you stay during an evacuation? ___ catheter (other than urinary)
___ home ___ Will you be alone? ___ severe respiratory illness
___ Yes ___ No ___ With family/friends ___ oxygen tank number of hours/day
___ evacuation shelter Can you get to an ___ do you have a portable tank?
evacuation shelter? ___ Yes ___No ___ Yes ___ No
If No, check the appropriate transportation ___ severe mental handicap
needed: ___ standard vehicles (car, van) ___ severe mental illness
___ wheelchair equipped ___ ambulance ___ end-stage Alzheimer's
Will a caregiver accompany you to the shelter? ___ chronic incontinence
___ Yes ___ No ___ advanced senile dementia
__________________________________________ ___ unstable Gran Mal seizures
Other arrangements:________________________ ___ require complex dressing changes _____________________________________ ___ unstable Gran Mal seizures _____________________________________ ___ moderate to severe symptomatic HIVAIDS Have you made arrangements for your pets
since they are not allowed in evacuation
shelters? ___Yes ___ No___ medically dependent on electricity
equipment: ____________________________
_______________________________________ _________________________________________________________Emergency Contact
Name_____________________________
Relationship___________________________
Phone(day)______________(night)________Additional information: ________________
_____________________________________
_____________________________________
| I certify that the above
information is correct to the best of my knowledge. I understand
that I am responsible for any expenses associated with medical evacuation
and shelter at a hospital, medical facility, or nursing home as well as
medical transportation. I grant permission to medical providers,
transportation agencies and any others to provide care and disclose any
information necessary to respond to my emergency needs. I also give
local law enforcement permission to enter my home in case of an emergency. Signed ________________________________________________________Date _________________ |
Please mail this completed form to:
Attn:
Alfreda Stout
Craven Co DSS
P.O. Box 12039
New Bern, NC 28561-2039
Applicants will be screened by a member of Craven County Department of Social Services to ensure those with special needs receive care in the appropriate facility during an emergency. Those who are found to have special needs an American Red Cross shelter cannot provide will be contacted and informed of the shelter site to which they should report.
All information provided on this form is voluntary and confidential, however, it may be shared with emergency personnel to facilitate your quick and safe evacuation.
Due to the time required and limited resources to safely evacuate people with special needs, the evacuation process may be executed well in advance of the impending disaster. You must be ready to evacuate when told to do so by emergency officials. Please refer to the accompanying Red Cross pamphlet for information about items to take with you during evacuation.
If you have questions or need assistance filing out the form, please call 252-636-4900