Functional Needs Registry Form

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Everybody Has Needs - Do the Right People Know What Yours Are?

If you or someone in your household has a disability or a special medical need, the people whose job it is to respond when you call for help in an emergency need to know.

Whether it affects your entire community, your street or just your home, seconds can make a life-or-death difference. Having specific details about your special situation will significantly help us help you.

EMERGENCY RESPONSE DATA FORM:

Filling out this form is strictly voluntary and the data will be kept strictly confidential. It will be available only to local emergency assistance officials. Please print clearly and provide all information.

Your Information

Address

In an Emergency, please contact

For the following, please answer Yes or No

Do you have Alzheimer’s, Dementia or Psychiatric Disability?
Are you confined to bed?
Do you have a Developmental Disability (i.e. Autism, Mental Health issues, Intellectual Disability, etc?)
Are you on Dialysis?
Are you hard of hearing or deaf?
Do you live alone?
Mobility Impaired: do you need assistance walking?
Mobility Impaired: do you use a walker or cane?
Mobility Impaired: do you use a wheelchair or scooter?
Are you on life support?
Are you oxygen dependent?
Will you require transportation if you need to be evacuated?
Do you have your own transportation?
Do you have a service animal?
Do you have pets?
Are you ventilator dependent?
Are you visually impaired or blind?
Can you communicate verbally?