You Must Take an Active Role

You must take an active role

in your own safety

during an emergency

“Prepare Now” gives information on how to:

Build a disaster kit

Communicate with loved ones

Shelter in place

Evacuate (when necessary)

“Special Needs Registry” is included to identify, notify and assist people who are at risk during a disaster.

Disaster Supply Kit-96 Hours
Food and Nutrition / Personal Comfort
q Water
1 gallon/person for at least 4 days
q Food
4 day supply of canned and non-perishable food
q Aluminum Foil
q Paper cups, plates, towels, utensils
q Manual can opener / q Blankets
q Sleeping bags
q Warm clothing
q Sturdy shoes
Emergency Equipment / Other Necessities
q Flashlights/Extra batteries
q Battery Operated radio
q NOAA Weather Radio w/tone alert
q Whistle to signal for help / q Plastic bags
q Waterproof matches
q Knife
q Trash bags
q Local maps
q Duct tape
Personal Supplies / Extras
q Toothbrush/toothpaste
q Medications
q Soap
q 1=1 Hand Sanitizer
q Toilet paper
q Baby wipes / q Extra set of keys
q Cash – Credit Cards
q Playing cards, books, puzzles
q Pet food – Pet supplies
First Aid Kit!!!
Store all supplies in easy to carry container
(e.g. back pack) with ID tag
Important Information To Keep In
Your Disaster Supply Kit
My Name______
Address ______
______/ Phone______
Date of Birth ______
Contact Information
Local Contact
Name ______
Phone ______/ Primary Contact
Name ______
Phone ______
Medical Information
Doctor ______
Phone ______
Current Medications
______
______
______
______
______
______
______/ Pharmacist ______
Phone ______
Allergies
______
______
______
Medical Equipment/Special Needs
Addition Information
______
______
Insurance Agent______Phone ______
Medicare Card Number ______
Health Insurance Policy ______Number ______
Other Information
Veterinarian ______Phone ______
SHELTER IN PLACE
q STAY in the house
q Turn ON the RADIO for information
Listen to the radio until you’re told all is safe, or you should evacuate.
FOLLOW INSTRUCTIONS BY AUTHORITIES
q You may be asked to close windows and fire place dampers, and to turn off fans,
as well as heating and air-conditioning.
q Tell your family, neighbors, friends, caregiver where you are IN CASE OF
TORNADO
q Go to the basement or an interior room with the fewest windows and doors.
Protect yourself from flying debris. AVOID all windows!!
q IN CASE OF FIRE. Leave the building right away; wet some large towels and
jam them in the crack under the doors if you cannot leave. Stay as low as possible.
EVACUATION PLAN
q  In an emergency, TURN ON THE RADIO for information.
q  BEFORE an emergency happens:
Talk to family, neighbors, friends, and care providers about:
WHAT you would do in the event of an evacuation
WHERE you will go, and
HOW you will get in contact with each other
MAKE arrangements for pets
q Consider your TRANSPORTATION
Will you be able to drive? Will you need someone to pick you up? Who? At what
meeting place?
If that person is unable to reach you, who will provide a backup ride? How will
that person be contacted?
If you must have assistance for special transportation, who will call you?
q  WEAR appropriate clothing and sturdy shoes.
q  LOCK YOUR HOME
IF YOU HAVE ENOUGH TIME
q Shut off water, gas, and electricity if advised to --- only if you know how!
q Leave a note to tell others when you left and where you are going.
q TAKE YOUR “DISASTER SUPPLY KIT”
Camp Douglas
Special Needs Registry Application
The purpose of the Camp Douglas Special Needs Registry is to provide emergency responders in the Village of Camp Douglas with important information from individuals who may require assistance during an emergency, such as tornado, flood, blizzard, and power outage or disease outbreak.
THIS PROGRAM IS VOLUNTARY AND IN NO WAY ENSURES THAT THE INDIVIDUAL COMPLETING THIS FORM WILL RECEIVE IMMEDIATE OR PREFERENTIAL TREATMENT IN AN EMERGENCY. This program will merely provide the emergency response community with information that is pertinent to developing an effective response. The Camp Douglas Special Needs Registry in no way replaces the responsibility of individuals to have their own emergency plans.
Personal Information
Date of Application: / q New Application
Last Name / First Name / MI / Date of Birth / Sex
Street Address / City / Zip Code
Mailing Address (if different) / City / Zip Code
Primary Phone / Alternate Phone / Primary Language
Name of Subdivision, Development, Mobile Home Park, Apartment Building, Etc.
Living Situation
q Living Alone q With Spouse q With Children q With Parents q Other
Medical Information (Check and complete those that apply to your medical condition)
q Wheelchair Bound
q Walker
q Bedridden
q Hearing Impaired
q Sign Language
q Visually Impaired
q Seizures
q Diabetes / q Speech Impaired
q Memory Impaired
(Explain)______
q Ostomy Care
q G-Tube Feeders
q Special Dietary Needs
q Suction Machine
q Physically Disabled / q Developmentally
Disabled
q Mental Health Condition
q Required or Life
Sustaining Equipment
q Portable Oxygen
Machine
q Life Sustaining
Medications / q Oxygen Concentrator or
Ventilator
q Continuous
q Intermittent
q Other (Explain)
______
______
______
______
______
______
Explain any that have been checked above including listing any types of diagnosis, medications, etc.:
Emergency Contact Information
Primary Emergency Contact
Last Name / First Name / Relationship / Phone
Alternate Emergency Contact
Last Name / First Name / Relationship / Phone
Medical Provider
Physician Name / Phone
Pharmacy Name / Phone
Home Health Care Agency Name / Phone
Shelter Information
Will you have transportation to a shelter in an emergency?
q Yes q No
If you need assistance with transportation, check on of the following:
q Automobile q Bus q Van with wheelchair lift q Medical transportation required
Pet Information
Do you have pets that would require special attention if you were asked to evacuate your home? If so, indicate the number of:
q Service Dog q Cat(s) q Dog(s) q Other (Explain)
Applicant Additional Comments
Authorization Information
By signing/submitting this form, I/legal guardian agree that my name will be added to the Camp Douglas Special Needs Registry. I give the Village of Camp Douglas Emergency Management authorization to share this information with other community 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
Applicant Signature / Date
Authorized Guardian Signature / Date
Mail completed form to: Village of Camp Douglas, PO Box 200, Camp Douglas, WI 54618
For questions contact the Village Clerk’s Office at 427-3355.