Waushara County Voluntary Emergency Assistance Registry Application

Waushara County Voluntary Emergency Assistance Registry Application

For People with Special Needs During a Natural Disaster or County Emergency
IF YOU ARE JUST LOOKING TO SIGN UP FOR EMERGENCY DISASTER ALERTS OR EMERGENCY WEATHER ALERTS THROUGH OUR HYPER-REACH SYSTEM - Click Here to sign up!
IF YOU OR A LOVED ONE WOULD REQUIRE ASSISTANCE IN EVACUATION DURING A DISASTER, PLEASE CONTINUE WITH THE FORM BELOW.
The purpose of the Waushara County Voluntary Assistance Registry is to provide emergency responders in Waushara County with important information from individuals that may require assistance with evacuation or recovery efforts during or after a disaster such as a tornado, flood, blizzard, power outage, or disease outbreak. This program will provide the emergency response community with information that is pertinent to developing an effective response and does not replace the responsibility of individuals to have their own emergency plan.
THIS PROGRAM IS VOLUNTARY. THE COUNTY CANNOT GUARANTEE THAT THE INDIVIDUAL COMPLETING THIS FORM WILL RECEIVE IMMEDIATE TREATMENT IN AN EMERGENCY
Today's Date*

MonthDayYear
Date
New ApplicationUpdate of Previous Application
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemale
Address*

Street Address

Mailing Address if Different than Above

CityState / Province

Postal / Zip Code
My Phone Number*
Please enter a valid phone number.
YesNo
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Live AloneLive with SpouseLive with ChildrenLive with ParentsLive with CaregiverOther
Evacuation Information
I am NOT able to leave my home independentlyI will be able to leave on my own
YesNo
AutomobileVan/BusVan/Bus with Wheelchair LiftMedical Transport/Ambulance
YesNo
YesNo
YesNo
YesNo
Name and Relationship of caregiver:
Emergency Contact Information
Name of Emergency Contact (NOT living at the same address as you)*

First NameLast Name
Relationship to you:*
Emergency Contacts Phone Number
Please enter a valid phone number.
Family Care Information
YesNo
My ChoiceIRIS ProgramInclusaLakeland Care
Case Managers Name
By signing/submitting this form, I/legal guardian agree that my name be added to the Waushara County Voluntary Emergency Assistance Registry. I give Waushara County Emergency Management authorization to share this information (including health information) with other community emergency responders to facilitate an effective emergency response. I grant emergency responders permission to enter my home following a disaster-related event, if necessary, to assure my safety and welfare. I understand that information provided will be stored in a secure electronic database and will not be used for any other purpose or shared with another agency without my permission, and that I may ask that my name be removed from the Emergency Registry by sending a written request to the Emergency Management. I understand that I should call 911 if I am in an emergency, even though I have submitted information to the Registry. I understand that it is my voluntary responsibility to update the information I have provided at least once a year or when my information changes, whichever occurs first.
Applicant named on the form aboveAuthorized Guardian/POA for the Applicant named on the form above
Applicant Signature Authorizing Participation*
Authorized Guardian/POA Signature Authorizing Participation
Date Signing Authorization of Participation

MonthDayYear
Date
Should be Empty:

Waushara County Voluntary Emergency Assistance Registry Application

Evacuation Information

Emergency Contact Information

Family Care Information