Access and Functional Needs Registry

I am completing this form: *

For Myself

As a Caregiver for individual listed below

Personal Information

First Name*

Middle Name

Last Name*

Date of Birth *

Gender

Do you have a Telephone? *

Yes

No

Primary Telephone Number *

Type of Telephone *

Mobile

Land Line

Is this a TTY/TTD capable device? *

Yes

No

Secondary Telephone Number (if available)

Type of Telephone

Mobile

Land Line

Is this a TTY/TTD capable device?

Yes

No

Email

Address Information

Type of Residence*

Enter the Apartment/Condominium Name *

Enter the Names of the College and Residence Hall *

Enter the Group Home Name *

Enter the Mobile Home Park Name *

Physical Street Address *

Apartment/Unit Number

City/Town/Village *

Zip Code *

Is your Mailing Address different than your Physical Address? *

Yes

No

Mailing Street or P.O. Box Address (if different than Physical Address above) *

City/Town/Village *

State *

Zip Code *

Do you live at your physical address all year? *

Yes

No

I live at that address
From Month: *
To Month: *

Is your other physical address location in Dutchess County?

Yes

No

Physical Street Address Two *

Apartment/Unit Number Two

City/Town/Village Two *

Zip Code Two *

Evacuation Plan

If I have to evacuate, I will go to:*

Other reason for needing evacuation assistance (Please specify)

Please Tell Us About Yourself

Do you need transportation assistance when evacuating? *

Yes

No

If yes, please select any that apply
   I need a wheelchair-equipped vehicle.
   I can transfer from a wheelchair to a seat.
   I am bedridden and require stretcher transport.
   My weight is over 250lbs and I will need more than one person to assist me.
   None of the above.

Please select any/all that apply and may help first responders in assisting you.

I am:

Legally Blind

Visually Impaired

Completely Bedridden

Deaf

Hard of Hearing

Non-Verbal

Partially Verbal

On Autism Spectrum

Wanderer risk

Fall risk

Non-English speaking/reading

Pregnant
If pregnant, please enter estimated due date.

I have:

Intellectual/Developmental Disability

Learning Disability

Behavioral/Emotional Health Issue

Dementia/Alzheimer's

Epilepsy/Seizure

Speech Impairment

Children in home under two

Physical Disability

Please use this space to tell us anything else first responders should know.

I do not have:

Access to a motor vehicle

Radio or a television

Telephone

Municipal water

Generator

Internet

An emergency supply kit

I rely on the following:

Walker/Cane

Wheelchair

Motorized Wheelchair

Attendant to assist in ambulating

American Sign Language Interpreter

Service Animal

Prosthetic limb(s)

Dialysis

Constant Skilled Nursing Care

Home Modification (i.e. locks, lifts, child security)

Hearing aids, glasses, dentures

Medication If you have medication, please enter the location of medication.

I require the following medical equipment that is not easily transportable:

Oxygen concentrator or cylinder

Ventilator

Suction machine

Specific equipment needed (Please specify)

Are your access/functional needs temporary or permanent? *

Permanent

Temporary

If the condition(s) is temporary, please provide an estimated date when the condition will be resolved.

Caregiver Name (if applicable)

Caregiver Phone Number

Caregiver's Secondary Phone Number if available

Relationship to registrant (if any)

Disclaimer

I understand that my participation in this registry is voluntary and all information submitted will be secured and held strictly confidential and used only for emergency purposes. I hereby request registration in the Dutchess County Voluntary Access and Functional Needs Registry.

By signing/submitting this form, I/legal guardian agree that my name and personal information provided therein this document will be added to the Dutchess County Access & Functional Needs Registry. I give the Dutchess County Department of Emergency Response (DER) authorization to share this information with other community emergency responders (such as Emergency Medical Services (EMS), Fire Departments, and area law enforcement) in the event of an emergency in order to facilitate an effective response. AFN Registry information will not be shared with others in non-urgent events. Information will be shared with United Way 211, who is a contracted agency with DER to facilitate aspects of this program and the notification process in the event of an emergency. By signing/submitting this application, you are granting emergency responders permission to enter your home following an emergency or disaster situation, if necessary, to assure your safety and welfare.

I understand and accept the terms of the Disclaimer and authorization.*

Municipal Information

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Who Should Complete This Registry Form?

How to Submit the Registry Form

* = Required

Personal Information

Address Information

Evacuation Plan

Please Tell Us About Yourself

Disclaimer