2012 Coastal Health District –Residents with Functional and Medical Needs Evacuation Registration
NOTE: Please PRINT information on both sides of this form and mail it to the return address on the back. REGISTRATION must be UPDATED and submitted ANNUALLY.
REQUIRED Personal Enrollment Data:
(One Person Per Form)
Date of Application:______New Application or Updated of Existing Application (Circle one)
Name: Sex: M F
Last ______First ______Middle ______
Street Address: ____Apt ______
Street City County Zip
Mailing Address: ______
(If different from above) City State Zip
Primary phone: (______) ______-______Date of Birth: _____ Age: ______Weight: _____ lbs
Cell phone: (______) ______-______Alternate phone number: (______) ______-______TDD?______
Primary Language: ______Height: ______ft. ______in.
Level of English Proficiency if English is not Primary: ______
Residence Type*: / Single Family Home/Duplex / Mobile Home Park/Trailer / Apartment/Condo
Other (specify) ______
Name of subdivision, mobile home park or apartment complex
______
*Residents living in Nursing Homes, Assisted Living Facilities, and Personal Care Homes MUST follow the emergency plan established by the facility’s administration.
Living Situation: / Living Alone / Living with Parents / Living with Children/Family
Living with Friend / Living with Spouse / Other (specify)______
Name of contact in your home: ______
Name of Spouse______Is spouse registered? YES NO
Emergency Contacts
(Local) Name: ______/ Relationship: ______/ Phone: (_____) ______-______
(Non-Local) Name: ______/ Relationship: ______/ Phone: (_____) ______-______
Functional Needs
Check All that Apply:
Medical Dependence on Electricity / Cognitive Impairment / Speech Impairment
O2 Concentrator, Nebulizer / Anxiety/Depression / Vision Loss/Impaired
Other ______/ Mental Health Problem / Hearing Loss/Impaired
Oxygen Company ______/ Alzheimer’s/Dementia / Incontinence
Intellectual disabilities / Dietary Restrictions / Service Animal
Allergies to foods / Communication Aids/Servies / Weight
Walker/Cane/Wheelchair (circle one) / Bedridden / Morbid Obesity
Activities of daily living require:
Durable Medical Equipment (DME)
Consumable Medical Supplies (CMS)
Personal Assistance Services (PAS) / Assistance with medications
Refrigeration Required / Sleeping Accommodations
Accessible cots
Crib
Other: ______
List Devices ______
Access to transportation
wheelchair accessible vehicle
Individualized assistance
transportation of equipment required / Assistance with activities of daily living
eating
taking medication
Dressing and undressing
Transferring to and from a wheelchair or other mobility aid
Walking
Stabilization
Bathing
Toileting
Communicating
Underlying Health Conditions: ______
Medical Needs
Check All that Apply:
IV Medication / Requires Medical Observation(s) / Terminal
Feeding Pump / Open Wounds/Decubitus / Respirator Dependent
Suction / Unstable / Contagious Condition
Dependent on power operating equipment to sustain life / Ongoing Treatment
Medical Diagnosis: ______/ Requires a licensed care provider to perform the following: ______/ Other______
Assistance Required
A Caregiver SHOULD travel with Registrant. Do you have a caregiver? YES NO
Caregiver Name: ______Caregiver Phone: (______) ______-______
Will your caregiver travel with you on the bus? YES NO
Do you have a pet or service animal that needs to travel with you? YES NO
What type of service animal? ______
What type of pet? ______
Do you have proof of vaccination for your pet? YES NO
Do you have a pet carrier for your pet? YES NO
Do you need Transportation to a Special Needs Staging Area in the event of a disaster? YES NO
If “YES,” Indicate type of Transportation: BUS Wheelchair Van Ambulance
DEPARTMENT OF PUBLIC HEALTH – COASTAL HEALTH DISTRICT –Functional and Medical NEEDS REGISTRATION
Other Medical Information
Primary Doctor Name: ______/ Phone: (______) ______-______
Home Health Agency Name: ______/ Phone: (______) ______-______
Other Health Service Provider: ______
Other Health Service Provider: ______
Pharmacy Name: ______
Medicaid: ______
Medicaid ID:______
Waiver: ______
Medicare: ______
Medicare ID: ______/ Phone: (______) ______-______
Phone: (______) ______-______
Phone: (______) ______-______
Phone: (______) ______-______
Phone: (______) ______-______
Phone: (______) ______-______
Health Insurance Company Name: ______
Insurance Policy #______
Insurance Group #______
Case Manager (Name and Organization): ______
______/ Phone: (______) ______-______
Phone: (______) ______-______
Case Manager Email: ______
______
Allergies:______
______
Consent
By signing this form, I agree that the information contained is accurate and truthful to the best of my knowledge.
Signature: ______Date: ______
Person Completing this Form? __Self __ Other (name and Phone number):______
Address/Company: ______Phone: (______) ______-______
IMPORTANT NOTES:
- In an actual emergency, coordinating agencies will try to provide the necessary evacuation assistance, but this cannot always be assured.
- To best guarantee personal safety, individuals should make plans and follow government emergency evacuation guidelines.
- Your personal caregiver SHOULD accompany you to the Emergency Shelter.
- Depending on your health status you may be transported to an American Red Cross Emergency Shelter or admitted to an inland healthcare facility.
- Residents living in a Nursing Home, Assisted Living Facility and Personal Care Home MUST follow the emergency plan established by the facility’s administration.
Mail Completed Form to:
Your County Health Department
(See contact list below) / Information regarding this form or the registration process can be obtained by calling the Department of Public Health – Coastal Health District at (912) 644-5200 or (912) 262-2300
Medication List
Please list your current medication(s):
______
This section to be Completed by the Coastal Health District
Date Rec’d: ______Date Updated: ______County: ______Evac Zone:______Triage Code: ______
Mail completed form to the following address in your county of residence. For more information about the Functional and Medical Needs Registry, call the phone number for your county, listed below:
BryanCounty Health Dept. CamdenCounty Health Dept.
ATTN: Joanne Burnsed ATTN: Debbie Melton
P. O. Box 9 905 Dilworth Street
Pembroke, GA31321-0009 St. Marys, GA31558
912-653-4331 912-882-8515
ChathamCounty Health Dept. EffinghamCounty Health Dept.
ATTN: Cathy Schmid ATTN: Cindy Grovenstein
1395 Eisenhower Drive P.O. Box 350
Savannah, GA31406 Springfield, GA31329
912-353-3255 912-754-6484
GlynnCounty Health Dept. LibertyCounty Health Dept.
ATTN: Sharon Smith ATTN: Annie Washington
2747 4th Street P.O. Box 231
Brunswick, GA31520 Hinesville, GA31310
912-279-3350 912-876-2173
LongCounty Health Dept. McIntoshCounty Health Dept.
ATTN: Kathy Rowell ATTN: Paige Lightsey
P.O. Box 279 P.O. Box 231
Ludowici, GA31316 Townsend, GA31331
912-545-2107 912-832-5473