Special Needs Registry

2. PERSONAL INFORMATION
4. Date of Application:*
   Date of Application:
5. New Application or Update of Previous Application*
   -- Select One --NewUpdate
7. Last Name*
8. First Name*
9. Middle Initial
11. Date of Birth*
12. Gender*
16. ADDRESS
18. Physical Street Address*
20. City*
21. State*
22. Zip Code*
24. Mailing Address (if different)
26. City
27. State
28. Zip Code
30. Primary Phone Number*
31. Alternate Phone Number
33. Email Address (Optional)
37. For the Hearing Impaired:
39. Do you use sign language?

    1. Yes
    2. No
40. TTD/TTY #:
44. Name of Subdivision, Mobile Home Park, Apartment Building, Etc.
45. Primary Language*
49. MEDICAL INFORMATION (Check those that apply to your medical condition)

    1. Hearing Impaired
    2. Asthmas, Ephysema, or COPD
    3. Visually Impaired
    4. Seizures
    5. Speech Impairment
    6. Memory Impaired (specify condition below)
    7. Developmentally Disabled
    8. Mental Health Contion
    9. Ongoing contagious condition (specify condition below)
    10. Bedridden
    11. Wheelchair Bound
    12. Ostomy Care
    13. Weight in excess of 400 pounds
    14. G-tube Feeders
    15. Insulin Dependent
    16. I.V. Medication
    17. Walker
    18. Incontinence Supplies
    19. Refrigeration for Medication
    20. Special Dietary Needs (Explain below)
    21. Portable Oxygen Machine
    22. Oxygen Concentrator or Ventilator (specify Continuous or Intermittent below)
    23. Other (Please explain below)

51. * If you require a special diet and must go to a shelter, be prepared.  Pack and bring with you the appropriate tools.

53. If you checked any of the items listed above, please explain here:
55. Any other required life-sustaining equipment or medication
57. Medication Management: You are strongly encouraged to complete a "Vial of Life" form listing all medications. If the form is not attached, please contact the City of Conover Fire Department at (828) 464-1295 for more information.
58. Attach Vial of Life form here:
62. EMERGENCY CONTACT INFORMATION
64. In State Emergency Contact
66. First Name
67. Last Name
69. Relationship
70. Phone Number
72. Out-of-State Emergency Contact
74. First Name
75. Last Name
77. Relationship
78. Phone Number
82. MEDICAL PROVIDER INFORMATION (Fill in all that apply)
84. Physician Name
85. Physician Phone Number
87. Pharmacy Name
88. Pharmacy Phone Number
90. Home Health Care Agency Name (or personal caregiver)
91. Agency Phone Number
93. Respiratory Equipment Provider (if applicable)
94. Provider Phone Number
98. SHELTER INFORMATION
100. 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, check one of the following:

     1. Automobile
     2. Bus
     3. Van with wheelchair lift
     4. Medical transport required
105. PET INFORMATION
107. Do you have pets that would require special attention if you were asked to evacuate your home? If so, indicate the number of:
109. Dogs
     -- Select One --12345>5
110. Cats
     -- Select One --12345>5
111. Service Animal
     -- Select One --12345>5
112. Other
     -- Select One --12345>5
114. If you selected other, please describe:

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.

120. EMERGENCY PLANNING
122. In case of emergency, do you plan to? (Select all that apply)

     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
126. AUTHORIZATION INFORMATION
128. By signing this form, I / legal guardian agree that my name be added to the City of Conover Special Needs Registry. In the event of an emergency, I hereby authorize the exchange of information between Catawba 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.
130. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.*

     1. I Agree
132. Applicant Signature (Please type your full name here)*
133. Date*
     Date
135. Authorized Guardian Signature (Please type your full name here)
136. Date
     Date
138. If you have questions regarding this form? Contact Conover Fire Department at (828) 464-1295
Leave This Blank:


140. 1. Receive an email copy of this form.
141. Email address

     This field is not part of the form submission.

142. Submit

* indicates a required field