The Arc of NORTHEAST MS/TEMA SPECIAL NEEDS REGISTRY

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The Arc OF NORTHEAST MS/TEMA SPECIAL NEEDS REGISTRY

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TIPPAH COUNTY SPECIAL NEEDS VOLUNTARY REGISTRATION FOR THE DISABLED AND ELDERLY

REQUIRED PERSONAL ENROLLMENT DATA:

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip:

Mail Address:

City:

State:

Zip:

Email:

Home Telephone:

Cell Number:

and/or Supervisor's Name:

Directions to your Residence:

Which (Volunteer) Fire District Serves Your Area:

List a Public Building Such as a Church, Park, Fire Department, Etc. That You Live Close To:

Emergency Contacts:

(Local) Name:

Phone

(Non-Local) Name:

Phone

Special Medical Needs - Mobility (Check All That Apply):

Ambulatory (Can Walk)

Non-Ambulatory (Bedridden)

Walk

Independent

With Assistance

With Cane

With Walker

Subject's Weight

Under 200

201 - 300

Over 300

Health Issues:

Impairment

Hearing

Sight

Speech

Prosthetic

Communication

ASL Interpreter

Communication Board

Other

Describe any Service Animal You Have:

Equipment

Feeding Tube

Life Support

Suction Unit

Oxygen

If you get Dialysis, where do you get it:

Meds

I.V. Fluids

Insulin

Insulin Pump

Other

Contagious Disease or Alergies:

Mental Health Issues:

Special Diet Type:

Heart Condition:

Epilepsy:

Terminal Condition:

General Health Condition

Good

Fair

Poor

Guarded

Other/Comments

It is your responsibility to bring all your medications, identification, health insurance cards, and any other special equipment/needs to the shelter, if a shelter is available

Assistance Required:

Do you have a caregiver who will be with you?

Yes

If "Yes", name:

Do you own accessible transportation that TEMA could use to transport individual to the Shelter?

Yes

If "Yes" what type of transportation

Year:

Make and Model:

Color:

Carrier or Lift:

Medical Support Information:

Family Doctor:

Doctor Phone:

Pharmacy:

Pharmacy Phone:

Home Medical Equipment Provider:

Provider Phone:

Health Insurance Company:

Health Ins Phone:

Additional Information/Comments:

Personal Emergency Plan

The purpose of the voluntary Tippah County Special Needs Registry is to provide emergency responders and volunteers with information from individuals that may require assistance during a disaster. The program is voluntary and in no way ensures that the individual completing this form will receive immediate or preferential treatment in an Emergency. This Registry will merely provide the emergency response community with information that is pertinent to the developing an effective response. The Tippah County Special Needs Registry in no way replaces the responsibility of individuals to have their own emergency plan. Please have your personal emergency plan in place before a disaster happens!! Be Prepared!!

Authorization Information

By signing my name below or completing this form on the Internet, I certify that I'm the person identified in this personal information section above or the legal guardian of that person. By signing/submitting this form, I/Legal Guardian agree that the applicant's name be added to the Tippah County Special Needs Registry. I give the Tippah County emergency management, the Arc of Northeast MS, rescuers and volunteers authorization to share this information with other community emergency responders in the event of an emergency in order to facilitate an effective response.

If necessary, I grant permission to medical providers, emergency personnel and volunteer rescuers, who are working under the direction of these agencies to provide care and disclose any information necessary to serve my needs. Information will be kept confidential and only used in the event of an emergency or disaster. It does not guarantee that emergency agencies and personnel will be able to provide assistance in every type of emergency or disaster. Tippah County Emergency Managemetn, Tippah County Special Needs Registry, The Arc of Northeast Ms, volunteer responders shall not be held liable for any claim, based upon good faith, failure to exercise or perform a function or duty on the part of carrying out a local disaster preparedness plan. By submitting your voluntary application by Internet, you agree that you have authorized this information to be relaease to TEMA and The Arc of NorthEast MS in the event of a Disaster.

The yearly updating of this form is your sole responsibility. This form can be updated as needed by mail. For Internet updates/information send questions to www.arc@dixie-net.com or call us at 662-993-9486. When you have completed this form, please save it to your files to use in yearly updates and then email application to www.arc@dixie-net.com. We appreciate your help and time in completing this form.

The Arc of Mississippi