Specific Needs Registry Form

Today's Date

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Application Type

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Personal Information

First and Last Name

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Date of Birth

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Sex

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Home Address

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City

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State

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Zipcode

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Name of Subdivision, Mobile Home Park, Apt. Building, etc

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Applicant Primary Phone

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Living Situation

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Applicant Alternate Phone

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Email Address

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Medical Information

Medical Information (check all that apply)

Wheelchair dependent Mental health condition

Walker/cane

Bedridden

Hearing impaired

Visually impaired

Seizures

Speech impaired

Memory impaired

G-tube feeders

Electricity dependent medical device

Dialysis dependent

Mental health condition

Special dietary needs

Required or life-sustaining equipment

Portable oxygen machine

Suction machine

Oxygen concentrator-continuous

Oxygen concentrator-intermittent

Ventilator

Life sustaining medications

Physical disabilities

Ostomy care

Developmental disabilities

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Emergency Contact Information

Primary Emergency Contact Name

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Primary Contact Relationship to Applicant

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Primary Contact Phone

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Alternate Emergency Contact Name

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Alternate Contact Phone

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Physician Name

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Physician Phone

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Pharmacy Name

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Pharmacy Phone

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Affliated Institution/Agency/Organization

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Affliated Institution Phone

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Emergency Transportation

Can you, a family member or friend provide transportation to a shelter in an emergency?

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If yes, who will provide transportation to a shelter?

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If other, please list who will provide transportation?

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Do you have a service animal that would require special attention if you had to evacuate?

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If yes, please list requirements for your service animal:

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Form Completed by:

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By submitting this form, I/legal guardian agree that my name be added to the Pennington County Specific Needs Registry. I give Pennington County Emergency Management authorization to share this information with other community emergency responders in the event of an emergency in order to facilitate an effective response. I grant emergency responders permission to enter my home following an emergency event or disaster situation, if necessary, to assure my safety and welfare.