Voluntary Registration for People With Special Needs

This registry is for full and part-time Warren County residents that may need additional assistance during an emergency. Special needs include but are not limited to: disabilities, chronic conditions, special healthcare needs, and language barriers. The information that you provide may help responders meet your needs during an emergency. If you cannot fill out this form on your own, please have a family member, caregiver or other representative complete the form and submit on your behalf. This information needs to be confirmed and updated annually.

Fields marked with an asterisk (*) are required.

Registrant Details

Physical Address

Is your physical address also your mailing address?
Mailing Address

TDD/TDY (for hearing impaired)

Are you capable of receiving communication in English?

Are you out of state for a period of time?

Emergency Contact

Life Support Systems

Oxygen
Tank or Concentrator?
Dialysis
Home or Clinic?

Electrical

Please check any electrical devices that you use:

Do you require a 24 hour caregiver?

Mobility

Are you confined to a bed?
Do you need assistance walking?

Mobility Aids

Please check any mobility aids that you use:

Sensory, Cognitive and Psychiatric Conditions

Please check all conditions that apply:

Evacuation Requirements

If I have to evacuate I will go to

Do you need assistance evacuating?
Have you arranged for someone to help you evacuate?
Appropriate transportation type needed

Pets

Do you have pets?

Type of Pets

Have you arranged for your pet(s) to be cared for in the event you need to evacuate?
Will your pet(s) need to be evacuated and sheltered?

By registering, I hereby consent and pre-authorize emergency response personnel to enter my home during search and rescue operations if necessary to assure my safety and welfare during an emergency or natural disaster.