Special Needs Registry Form

Prefix: First Name: Last Name: Suffix:

Street Address: City: Zip:

Email Address:

Home Phone: Work Phone: Date of Birth (mm/dd/yyyy): Gender:

Primary Language Spoken: Do You Have A File / Vial of Life? Check Here if You Would Like One:

Emergency Contact Information

Prefix: First Name: Last Name: Suffix:

Street Address: City: State: Zip:

Home Phone: Mobile Phone: Work Phone:

Special Needs (Please Check All That Apply)

Deaf:	Cognitive Loss:	Diabetes:	Multiple Sclerosis:
Blind:	Alzheimer's / Dementia:	Colostomy:	Muscular Dystrophy:
Speech:	Autism:	Ileostomy:	Parkinson's:
Mobility:	Mood disorder / mental illness:	G-Tube:	Paralysis (Full or Partial):
Emphysema:	Developmentally Disabled:	Catheter:	Cerebral Palsy:
Cardiac:	Weight (over 250 lbs):	Contagious / Infection:	Seizures:

I have another disability [Please separate multiple items wiht a semi-colon (;)]:

I Have a Service Animal (i.e. Seeing Eye Dog) | I Have a Pet | Number of Pets:

I am Confined to My Home | I Need Transportation | I Need Assistance with Basic Care | I Live Alone

Does Your Care Require The Use of Any of the Following? (Check All That Apply):

Oxygen | Ventilator / Respirator | Dialysis | IV Support | Wheelchair/ Walker, Cane, Crutches

Other [Please Separater Multiple Items with a Semi-Colon (;)]:

The Special Needs Registry is a cooperative public safety program in St. Clair County. It is designed to ensure the safety of those residents of St. Clair County that are most vulnerable to emergencies and disasters, the elderly and infirmed and those with various disabilities. The information you provide about your health and medical conditions may be shared with the Health Department, Police, Fire and other emergency workers to assist them in responding to a disaster or emergency. You may revoke your consent to sharing information at any time by sending a written request to: St. Clair County Emergency Management Agency, 110 West Washington Street, Belleville, IL 62220. "Providing this information does not insure that emergency responders will be able to provide services to you in an emergency but will assist them in responding appropriately based on available resources." By submitting this information, you consent to sharing information on this form.

I certify that the information provided on this form is correct. I understand that I am responsible for all expenses associated with medical evacuation and shelter at a hospital, nursing facility or for any specialized equipment needed in a special needs shelter. Furthermore, I hereby grant permission to the St. Clair County Office of Emergency Management to release this information to other emergency response or human service agencies or officials. Additionally, I give local law enforcement and/or medical personnel permission to enter my home in case of an emergency. It is my responsibility to update the information on this form as needed. Please mail this completed form to the address above. You may also email it the address listed above.