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2. 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.
4. Date and Time*
   Date and Time

   Date and Time
6. Choose one:*

   1. New Application
   2. Update of Previous Application
8. Who is filling out this form?*

   1. The Applicant
   2. Someone else on behalf of the applicant
10. If you are filling out this form for someone else or on behalf of the applicant, please fill in your contact information
12. First*
13. Last*
15. Phone*
16. Email Address*
18. Personal Information
20. Applicant's Full Name
22. First*
23. Middle*
24. Last*
26. Applicant's Date of Birth
28. Month*
    -- Select One --123456789101112
29. Day*
    -- Select One --12345678910111213141516171819202122232425262728293031
30. Year
    -- Select One --2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
32. Gender*

    1. Male
    2. Female
34. Address*
36. Mailing Address (if different)
38. Name of Subdivision, Mobile Home Park, Apartment Building, etc.:
40. Main Phone Number*
41. Alternate Phone Number
43. Email Address
45. Marital Status

    1. Single
    2. Married
    3. Divorced
    4. Widowed
    5. Separated
46. Living Situation*

    1. Live Alone
    2. With Spouse/Partner
    3. With Children
    4. With Parents
    5. Other
48. Primary Language*
49. Do you need the assistance of a translator for English?

    1. Yes
    2. No
51. For the Hearing Impaired: Do you use sign language?

    1. Yes
    2. No
52. TTD / TTY #:
54. Medical Information
56. (Check all that apply to your medical condition)

    1. Hearing Impaired
    2. Asthma, Emphysema, or COPD
    3. Visually Impaired
    4. Seizures
    5. Speech Impaired
    6. Memory Impaired
    7. Developmentally Disabled
    8. Mental Health Condition
    9. Ongoing Contagious Condition
    10. Bedridden
    11. Wheelchair Bound
    12. Ostomy Care

    1. Weight in excess of 400 pounds
    2. G-tube Feeders
    3. Insulin Dependent
    4. I.V. Medication
    5. Walker
    6. Incontinence Supplies
    7. Refrigeration for Medication
    8. Special Dietary Needs
    9. Portable Oxygen Machine
    10. Oxygen Concentrator or Ventilator
    11. Other
58. Do you require either of these?

    1. Oxygen Concentrator
    2. Ventilator
59. Use of your Oxygen Concentrator or Ventilator is:

    1. Continuous
    2. Intermittent
61. Any other required or life-sustaining equipment or medication:
63. Emergency Contact Information
65. In-State Emergency Contact
67. First*
68. Last*
70. Relationship*
71. Phone*
73. Out-Of-State Emergency Contact
75. First
76. Last
78. Relationship
79. Phone
81. Medical Provider Information (Fill in all that apply)
83. Physician Name
84. Physician Phone
86. Pharmacy Name
87. Pharmacy Phone
89. Home Health Care Agency (or personal caregiver) Name
90. Home Health Care Agency (or personal caregiver) Phone
92. Respiratory Equipment Provider Name
93. Respiratory Equipment Provider Phone
95. Transportation Information
97. Geographic Location

    1. Flood Plain
    2. Isolated/Difficult to Reach
    3. Mobile Home
99. Can you, a family member or friend provide you with transportation to a shelter in an emergency?*

    1. Yes
    2. No
101. If you need assistance with transportation, which of the following best suits your need:

     1. Car
     2. Bus/Taxi
     3. Van with Wheelchair Lift
     4. Medical Transport Required
103. Pet Information
105. Do you have any pets that would require special attention if you were asked to evacuate your home?*

     1. Yes
     2. No
107. Please indicate the number of:
109. Dogs*
110. Cats*
111. Service Animal*
114. Other*
116. 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.
118. Emergency Planning
120. In case of an emergency, I plan to...*

     1. Stay with family or others
     2. Stay at home
     3. Evacuate to an appropriate facility, independently
     4. Evacuate to an appropriate facility with caregiver
122. 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.

Leave This Blank:


124. 1. Receive an email copy of this form.
125. Email address

     This field is not part of the form submission.

126. Submit

* indicates a required field