Functional Needs Registry Enrollment Form

South Central Regional Functional Needs Registry Enrollment Agreement Accurate Information and Expiration: The information submitted on my Enrollment Form is true and correct. I agree to keep my enrollment information up-­‐to-­‐date as changes occur. I understand that my enrollment in the Functional Needs Registry will expire annually. I will receive an annual reminder to update my enrollment information and renew my enrollment. Privacy of Information: The enrollment information submitted to the Registry is protected and used in strict compliance with the Registry’s Privacy of Information Policy. The attached policy describes how information is used, security measures, and your rights. Please carefully read the copy provided. Authorization to Release Information: I have read, understand, and agree to the terms of the Privacy of Information Policy. I authorize administrators of the South Central Regional Functional Needs Registry to use and release my enrollment information within the limitations and for the purposes described in the policy. Personal Preparedness: I understand and agree that participation can not and does not guarantee that I will receive assistance in a local emergency. Disaster conditions are highly unpredictable. Always call 911 in an emergency. Everyone should plan and prepare to be self-­‐sufficient for three to five days. Please carefully review and use the preparedness planning information provided. Release of Liability: I hereby agree to the fullest extent permitted by law, to indemnify, defend, and Hold Harmless the South Central Regional Functional Needs Registry Coalition, its officers, agents, and employees from and against claims, damages, losses and expenses, including but not limited to attorney’s fees, arising out of or resulting from performance of this Agreement, that results in any Claim for damage whatsoever, including without limitation, any bodily injury, sickness, disease, death, or any injury to or destruction of tangible or intangible property, including any loss of use resulting there from, and that are caused in whole or in part by the intentional or negligent act or omission related to the South Central Regional Functional Needs Registry. Term: The term of this agreement shall be perpetual. I understand I may withdraw from the Disaster Registry at any time and revoke all permissions granted by notifying my local emergency manager or Two Rivers Public Health Department. Voluntary Agreement: I hereby voluntarily agree to the terms herein and request to be enrolled in the South Central Regional Functional Needs Registry: Registrant’s Signature: ______________________________________ Date: ___________________ Other signature, if the registrant is unable to sign: ___________________________________________ ___I obtained verbal permission. ___I have legal authority, specify: ________________ Initial: _______ Printed Name: ________________________________ Relationship: ___________________________ Address: ____________________________________ City: __________________ Zip: ______________ Phone: ( ) __________-­‐_______________ Email Address: ___________________________________ Mail to: Two Rivers Public Health Department; 701 4th Avenue, Suite 1; Holdrege, NE 68949 Questions or Assistance: 308-­‐995-­‐4778 South Central Regional Functional Needs Registry Privacy of Information Policy The South Central Regional Functional Needs Registry takes every precaution to protect the privacy of personal enrollment information in both written and electronic forms. Use of Information: Enrollment information will only be used for the purposes of:  Advanced planning and preparedness for a local emergency.  Guiding search and rescue personnel to those who will urgently need care.  Providing appropriate medical treatment, care and shelter.  Reuniting loved ones and care providers after the emergency. Your name and the precise location of your residence will be shared in advance with law enforcement, fire, and search and rescue personnel to ready them to respond to an emergency. When South Central Regional Functional Needs Registry activates emergency operations, some or all of the enrollment information collected may be shared on a need to know basis with the organizations that will be actively responding to the emergency. Those organizations include law enforcement, fire, search and rescue, emergency medical transportation, hospitals, health and human services agencies, and public utilities. Security of Personal Information: The South Central Regional Functional Needs Registry does not sell, rent, or publish enrollment information. Enrollment information will not be revealed to any unaffiliated third parties for their independent use, except if required by law. Personnel who are authorized to access enrollment information are specially trained and required to strictly adhere to procedures that protect the privacy of information. Computer information is managed by data processing professionals and protected by all appropriate safeguards to secure the information system from any foreseeable threat to its security. Your Rights: As an individual enrolled in the Disaster Registry, you have the right to:  Examine your enrollment information to ensure it is accurate and up-­‐to-­‐date.  Be informed of any unauthorized violation of privacy.  Know of any changes in policy related to the privacy of your information.  Withdraw from the Disaster Registry at any time and have all your enrollment information completely removed. If you have any questions regarding your privacy or the Disaster Registry, please contact: Two Rivers Public Health Department Buffalo County Emergency Management: 308-­‐233-­‐3225 701 4th Avenue, Suite 1 Dawson County Emergency Management: 308-­‐324-­‐2070 Holdrege, NE 68949 Franklin County Emergency Management: 308-­‐425-­‐6231 308-­‐995-­‐4778 Harlan County Emergency Management: 308-­‐928-­‐2147 Kearney County Emergency Management: 308-­‐743-­‐2442 Region 15 Emergency Management: 308-­‐995-­‐2250 South Central Regional Functional Needs Registry Enrollment Form Register online at: http://lancaster.ne.gov/emergency/needs/index.htm or mail to Two Rivers Public Health Department; 701 4th Avenue, Suite 1; Holdrege, NE 68949 I. Identifying Information Last Name: ______________________ First Name: _______________ Middle Initial: __________ Gender: ❑ Male ❑ Female Date of Birth (m\d\yr) : ____\____\ ____ Age: _____ Address: ___________________________________________ Unit # ________ Apt # ___________ City: ___________________________ County: ______________________ Zip: _______________ Phone: Work: _____________________ Home: ___________________ Cell: _________________ E-­‐mail: _________________________________ Email: ___________________________________ II. Emergency Contacts Primary Contact Name: ______________________________________________________ Relationship: ❑ Family ❑ Friend ❑ Caregiver ❑ Neighbor ❑ Legal Guardian ❑ Other or ❑ Organization, specify: _______________________________________ Phone: Work _____________________ Home: ____________________Cell: ___________________ E-­‐mail: ___________________________________________________________________________ Secondary Contact Name: ____________________________________________________________ Relationship: ❑ Family ❑ Friend ❑ Caregiver ❑ Neighbor ❑ Legal Guardian ❑ Other or ❑ Organization, specify: _______________________________________ Phone: Work: _____________________Home: ___________________ Cell: ____________________ E-­‐mail: ____________________________________________________________________________ III. Evacuation: If a local emergency requires you to leave your home, will you: ❑ go to friend or family member’s home ❑ need to go to a hospital or care facility ❑ go to a community shelter Will you need transportation? ❑ Yes ❑ No If yes, what type of transportation: ❑ automobile ❑ lift van ❑ ambulance (Over) IV. Your Health and Circumstances: Physician Name: __________________________________ Phone: ______________________ Please Check All that Apply, Check Marks mean Yes: ❑ Life-­‐Sustaining Equipment Required ❑ Uninterrupted Electrical Service is Essential Please list below the equipment that you use: ________________________________________________________________________________ ________________________________________________________________________________ ❑ Ventilator ❑ Supplemental oxygen ❑ Life Sustaining Medication ❑ Home Care Assistance ❑ Cardiac ❑ Blood Pressure ❑ Full time ❑ Daily ❑ Respiratory ❑ Diabetes ❑ Several days/week ❑ Monthly ❑ Other: ___________________ ❑ Service Animal ❑ Vision Impairment Type: ❑ Sight ❑ Hearing ❑ Service ❑ Low Vision ❑ Other: ___________________ ❑ Legally Blind ❑ Speech Impairment ❑ Mobility Impairment ❑ Walker ❑ Wheelchair ❑ Interpreter Required ❑ Scooter ❑ Immobile Language: ___________________ ❑ Hearing Impairment ❑ Mental or Behavioral Condition ❑ Hard of Hearing ❑ Deaf IV. Describe Diagnosed Medical Conditions, Health Needs, or Needed Accommodations: ____________________________________________________________________________________
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____________________________________________________________________________________ Submitted by (Name): _______________________________________________________________ Relationship: ❑ Family ❑ Friend ❑ Caregiver ❑ Neighbor ❑ Legal Guardian ❑ Other or ❑ Organization, specify: ________________________________________ Phone: Work: ____________________ Home: _____________________ Cell: ___________________ E-­‐mail: ____________________________________________________________________________