CALHOUN COUNTY 9-1-1 VOLUNTARY REGISTRY

The Calhoun County 9-1-1 emergency system and the Calhoun County Emergency Management Agency (CCEMA) welcomes you to the Emergency Preparedness Voluntary Registry for citizens who have special needs.

This program is voluntary and in no way ensures that the individual registering for this program will receive immediate or preferential treatment in an emergency. This program merely provides the emergency response community with information that is pertinent to developing an effective response. On a daily basis, 9-1-1 personnel and first responders will have access to this information and will use it to better serve you should you need to dial 9-1-1. This includes fire, police, and EMS personnel.

If you do not want to disclose your protected health information, please STOP now, and do not complete this form.

Instructions:

Complete this form for each household member with functional needs who may require help in an emergency.
If you have any questions regarding this form, please call (256) 435-0540 for assistance.

A. CONTACT INFORMATION

Primary Phone Number:

Alternative Phone Number:

Independence Needs

I am in a wheelchair or use a scooter I have a mobility limitation (such as paralysis or amputation) I have a service animal I am a bariatric patient

Medical Care Needs

I receive daily I.V. therapy or tube feeding I am on dialysis I am on oxygen or a ventilator I have life-sustaining medical equipment that needs electricity

Communication Needs

I am deaf I am blind

Transportation Needs I Need

Van with wheelchair lift Ambulance or medical transport

Describe any additional information to assist 9-1-1:

C. INFORMATION RELEASE AUTHORIZATION

By submitting this form, I hereby grant CCEMA and Calhoun County 9-1-1 authorization to use and share this information with Community Based Organizations (both private and public) and emergency responders including but not limited to fire departments, law enforcement agencies, emergency medical services, and local health care agencies in order to facilitate an effective emergency response. I also hereby grant emergency responders permission to enter my residence during an emergency if deemed necessary to assure my safety and welfare.

I hereby understand that by submitting this form I am agreeing to the release and transfer of my personal information herein by, between, and among CCEMA, Calhoun County 9-1-1, Community Based Organizations, and emergency responders, including their employees and agents. I also recognize that if I no longer desire my personal information to be shared by, between, and among these agencies and organizations that I have the option of having my information removed from the At Risk Registry within sixty (60) days after receipt of my written request to CCEMA.

Full name of Registrant or Legal Guardian giving authorization:

If signing as Legal Guardian, please provide your address, telephone number, and relationship below: