Special Needs Registry Form printable pdf download

SPECIAL MEDICAL NEEDS REGISTRY FORM

NAME:

GENDER: M

AGE: _____

ADDRESS

DIRECTIONS:

(Where you live)

TYPE DWELLING

Ground floor

Upper level

Trailer

House

Apartment

(check one)

TELEPHONE:

MAILING ADDRESSS

TTD/TTY:

(If different from above)

E-MAIL:

EMERGENCY

RELATIONSHIP:

CONTACT PERSON

PHONE:

ADDRESS

ALTERNATE PHONE:

CAREGIVER

PHONE:

PRIMARY CARE PHYSICIAN’S NAME:

CLINIC OR PRACTICE ADDRESS:

PHONE:

FAX:

Dialysis

____# of times per week

Refrigeration of meds

SPECIAL NEEDS

Wheelchair user

Bedridden

Ambulatory needs?

(check all that apply)

Have a Catheter

Feeding tube

Oxygen

Spare tank? Y

Interpreter? Language

Hearing

Walker

Respiratory units_____

Elec for medical equip

110V or 220V

(circle one)

Any additional

information on special

needs

Service animals are the only pets allowed at

Do you have a service

the shelter. What arrangements do you

dog?

have for other pets?

(check one)

In case of disaster, I

Stay home if possible

Go to special needs shelter

will

Stay with family or others

Need to go to hospital or ER

…(check all that apply)

Have transportation

Need ambulance transportation

Already have a written family

Require lift equipped van

disaster plan attached

I certify that the above information is correct to the best of my knowledge. I understand that I am responsible for all expenses

associated with medical evacuation and shelter at a hospital. I hereby grant permission to the Cumberland County Department of

Social Services, Cumberland County Emergency Services, and special needs shelter staff to release the information on this form

to other emergency response or human service professionals or officials as needed during times of disaster. I also give local law

enforcement permission to enter my home in case of emergency. I understand I am providing this information voluntarily.

Signature of applicant___________________________

Date___________

For person completing form if other than the special needs applicant:

Name__________________________________ Relationship to applicant__________________________

Phone number where you can be reached____________________

Signature________________________________

Date___________

Please return form to: Cumberland County Department of Social Services ATTN: District # 002

PO Box 2429 Fayetteville,

NC 28302

Special Needs Registry Form

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