Dutchess County Access & Functional Needs Registry Application

Who Should Complete This Registry Form?

You should complete this form if:

You are a temporary or permanent resident of Dutchess County, AND
You need assistance during an emergency and cannot manage on your own and/or you need other people to assist you if you must evacuate your home during an emergency, OR
You need first responders to understand any special needs you may have before entering your home to assist you.

How to Submit the Registry Form

Dutchess County offers many options for submitting this application. You can:

Complete the form online and click Submit at the bottom of the page.
Print and mail the Adobe Acrobat Portable Document Format (.PDF) version of your application to the address listed below using the U.S. Postal system.
Scan and submit your completed application to needsregistry@dutchessny.gov.
Send us a clear, intelligible voice recording of the applicant’s information.
Schedule an appointment with someone who can personally interview you to complete the application.

For alternative means of filing an application that are within reasonable accommodation standards, or to ask additional questions about the Dutchess County Voluntary Access and Functional Needs Registry, please call (845) 486-2080.

Dutchess County Department of Emergency Response (DER)
392 Creek Road
Poughkeepsie, N.Y. 12601
Phone: (845) 486-2080
Fax: (845) 486-3998

Access and Functional Needs Registry Form

All fields marked with an asterisk (*) are required

I am completing this form...: *

For Myself

As a Caregiver for the individual listed below

Please indicate if you are completing this form for yourself or for another individual.

Registrant Information

First Name* Please enter the First Name of the registrant.

Middle Name

Last Name* Please enter the Last Name of the registrant.

Date of Birth* Please enter the Date of Birth of the registrant (Format: MM/DD/YYYY).

Gender

Do you have a Telephone? *

Yes

Please indicate if the registrant has a telephone.

Primary Telephone Number* Registrant's Primary Telephone Number is invalid. Please enter a 10-digit phone number (Format: xxxxxxxxxx). Please enter the registrant's Primary Telephone Number.

Primary Telephone Type: *

Mobile

Land Line

Please indicate the registrant's Primary Telephone Type.

Is the Primary Telephone a TTY/TTD capable device? *

Yes

Please indicate if the registrant's Primary Telephone is TTY/TTD capable.

Secondary Telephone Number (if available) Registrant's Secondary Telephone Number is invalid. Please enter a 10-digit phone number (Format: xxxxxxxxxx).

Secondary Telephone Type (if available):

Mobile

Land Line

A Secondary Telephone Number for the registrant was provided. Please indicate the registrant's Secondary Telephone Type.

Is the Secondary Telephone a TTY/TTD capable device?

Yes

A Secondary Telephone Number for the registrant was provided. Please indicate if the registrant's Secondary Telephone is TTY/TTD capable.

Email Please enter the registrant's Email Address in the format: email@example.com.

Address Information

Primary Physical Address Information

Type of Residence* Please select the Type of Residence in which the registrant lives.

Enter the Apartment/Condominium Name* Please enter the Apartment/Condominium name.

Enter the Names of the College and Residence Hall* Please enter the College and Residence Hall names.

Enter the Group Home Name* Please enter the Group Home name.

Enter the Mobile Home Park Name* Please enter the Mobile Home Park name.

Physical Street Address* Please enter the Primary Physical Street Address of the registrant.

Apartment/Unit Number The Apartment/Unit Number of the registrant's primary address is invalid. Please enter numbers and/or letters only. The maximum number of characters is 10.

City/Town/Village* Please select the City/Town/Village of the Primary Physical Address of the registrant.

Zip Code* Please select the Zip Code of the Primary Physical Address of the registrant.

Is your Mailing Address different than your Physical Address? *

Yes

Please indicate if the registrant has a Mailing Address that is different than their Physical Address.

Mailing/P.O. Box Address Information

Mailing Street or P.O. Box Address (if different than Physical Address above)* Please enter the Mailing Street Address or P.O. Box Address of the registrant.

City/Town/Village* Please select the City/Town/Village of the registrant's mailing address.

State* Please select the State of the registrant's mailing address.

Zip Code* Please enter the Zip Code of the registrant's mailing address. Registrant's mailing address Zip Code is invalid. (Format: xxxxx or xxxxx-xxxx, all numbers).

Do you live at your physical address all year? *

Yes

Please indicate if the registrant lives at the Primary Physical Address all year.

Please specify the months in which you live at the address you entered into "Physical Street Address" above Start Month:* Please enter the Start Month of when the registrant begins residing in Dutchess County.
End Month:* Please enter the End Month of when the registrant finishes residing in Dutchess County.

Is your other physical address in Dutchess County? *

Yes

Please indicate if the registrant's Secondary Physical Address is in Dutchess County

Secondary Physical Address Information

Physical Street Address* Please enter the registrant's Secondary Physical Street Address.

Apartment/Unit Number The Apartment/Unit Number of the registrant's secondary address is invalid. Please enter numbers and/or letters only. The maximum number of characters is 10.

City/Town/Village* Please select the City/Town/Village of the registrant's secondary address.

Zip Code* Please enter the Zip Code of the registrant's secondary address.

Evacuation Plan

If I have to evacuate, I will go to:* Please select where the registrant plans to go in the event of an evacuation.

Emergency Contact Information

First Name* Please enter the First Name of the emergency contact.

Last Name * Please enter the Last Name of the emergency contact.

Primary Telephone Number * Emergency contact's Primary Telephone Number is invalid. Please enter 10-digit phone number (Format: xxxxxxxxxx). Please enter the emergency contact's Primary Telephone Number.

Primary Telephone Type *

Mobile

Land Line

Please indicate the emergency contact's Primary Telephone Type.

Is the Primary Telephone a TTY/TTD capable device? *

Yes

Please indicate if the emergency contact's Primary Telephone is TTY/TTD capable.

Secondary Telephone Number (if available) Emergency contact's Secondary Telephone Number is invalid. Please enter 10-digit phone number (Format: xxxxxxxxxx).

Secondary Telephone Type

Mobile

Land Line

A secondary telephone number for the emergency contact was identified. Please indicate the emergency contact's Secondary Telephone Type.

Is the Secondary Telephone a TTY/TTD capable device?

Yes

A secondary telephone number for the emergency contact was identified. Please indicate if the emergency contact's Secondary Telephone is TTY/TTD capable.

Email Please enter the emergency contact's Email Address in the format: email@example.com.

Alternate Emergency Contact Information

First Name

Last Name An alternate emergency contact's first name was identified. Please enter the alternate emergency contact's Last Name.

Primary Telephone Number Alternate emergency contact's Primary Telephone Number is invalid. Please enter 10-digit phone number (Format: xxxxxxxxxx). An alternate emergency contact was identified. Please enter their Primary Telephone Number (or email address in the corresponding field below).

Primary Telephone Type

Mobile

Land Line

Please indicate the alternate emergency contact's Primary Telephone Type.

Is the Primary Telephone a TTY/TTD capable device?

Yes

Please indicate if the alternate emergency contact's Primary Telephone is TTY/TTD capable.

Secondary Telephone Number (if available) Alternate emergency contact's Seocndary Telephone Number is invalid. Please enter 10-digit phone number (Format: xxxxxxxxxx).

Secondary Telephone Type

Mobile

Land Line

A secondary telephone number for the alternate emergency contact was identified, please indicate the alternate emergency contact's Secondary Telephone Type.

Is the Secondary Telephone a TTY/TTD capable device?

Yes

A secondary telephone number for the alternate emergency contact was identified, please indicate if this telephone is TTY/TTD capable.

Email Please enter the alternate emergency contact's Email Address in the format: email@example.com. An alternate emergency contact was identified, please enter their email address (or primary telephone number in the corresponding field above).

Other reason for needing evacuation assistance (Please specify)

Please Tell Us About Yourself

Do you need transportation assistance when evacuating? *

Yes

Please indicate if the registrant needs transportation assistance when evacuating.

Please identify any/all transportation accommodations 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 check any/all of the transportation accomodations that apply to the registrant.

Please select any/all of the following 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.
It was indicated that the registrant is currently pregnant, please enter the estimated due date.

Please select any/all of the following that apply and may help first responders in assisting you: I have a(n)...

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.
It was indicated that the registrant relies medication, please enter where the medication is located.

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

Please indicate if the registrant's access/functional needs are temporary or permanent.

Please provide an estimated date when the condition will be resolved.* Please enter an estimated date when the registrant's access/functional needs will be resolved.

Caregiver Information

Full Name (if applicable)

Primary Telephone Number Caregiver's Primary Telephone Number is invalid. Please enter a 10-digit phone number (Format: xxxxxxxxxx) A caregiver was identified. Please enter the Caregiver's telephone number (Format: xxxxxxxxxx).

Secondary Telephone Number (if available) Caregiver's Secondary Telephone Number is invalid. Please enter a 10-digit phone number (Format: xxxxxxxxxx).

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.*

Please check the box to indicate you have read the disclaimer.

I have reviewed the information entered above and confirm its correctness.*

Please check the box to indicate you have reviewed the information entered in the form.

Municipal Information

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Dutchess County Access & Functional Needs Registry Application

Who Should Complete This Registry Form?

How to Submit the Registry Form

Access and Functional Needs Registry Form

Registrant Information

Address Information

Evacuation Plan

Please Tell Us About Yourself

Disclaimer