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Lincoln County Special Population Registry Application

  1. The Special Population Registry provides vital information to emergency responders in the event of a 9-1-1 call and/or during a widespread disaster (e.g. hurricane, flood, blizzard, power outage, disease outbreak). This program is voluntary and individuals on the registry have the option to accept or deny assistance. Completion of this form in no way guarantees that the registered individual will receive immediate or preferential treatment in a disaster. Individuals should maintain a personal emergency plan.
  2. Choose one:*
  3. Who is filling out this form?*
  4. If you are filling out this form for someone else or on behalf of the applicant, please fill in your contact information
  5. Personal Information
  6. Applicant's Full Name
  7. Applicant's Date of Birth
  8. Gender*
  9. Marital Status
  10. Living Situation*
  11. Do you need the assistance of a translator for English?
  12. For the Hearing Impaired: Do you use sign language?
  13. Medical Information
  14. (Check all that apply to your medical condition)
  15. Do you require either of these?
  16. Use of your Oxygen Concentrator or Ventilator is:
  17. Emergency Contact Information
  18. In-State Emergency Contact
  19. Out-Of-State Emergency Contact
  20. Medical Provider Information (Fill in all that apply)
  21. Transportation Information
  22. Geographic Location
  23. Can you, a family member or friend provide you with transportation to a shelter in an emergency?*
  24. If you need assistance with transportation, which of the following best suits your need:
  25. Pet Information
  26. Do you have any pets that would require special attention if you were asked to evacuate your home?*
  27. Please indicate the number of:
  28. Individuals are responsible for caring for the needs of an assistance animal, including bringing food and other essential needs to the shelter. Service animals are allowed in shelters but must provide proof of current rabies vaccine. Pets may not be able to accompany you to the shelter. Pet friendly shelters may be available.
  29. Emergency Planning
  30. In case of an emergency, I plan to...*
  31. Authorization Information

    By submitting this form, I / Legal Guardian / Personal Representative agree that my name be added to the Lincoln County Special Population Registry. In the Event of an emergency I hereby authorize the exchange of information between Lincoln County Emergency Services and the individuals and agencies listed on this form. I grant emergency responders permission to enter my home following an emergency event or disaster situation, if necessary, to assure my safety and welfare.

  32. Leave This Blank:

  33. This field is not part of the form submission.