Waushara County Voluntary Emergency Assistance Registry Application
For People with Special Needs During a Natural Disaster or County Emergency
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
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Month
-
Day
Year
Date
Type of Application
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New Application
Update of Previous Application
Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Gender at Birth
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Male
Female
Address
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Street Address
Mailing Address if Different than Above
City
State / Province
Postal / Zip Code
Do you live in Waushara County Year-Round?
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Yes
No
If no, select ALL months you DO live in Waushara County
January
February
March
April
May
June
July
August
September
October
November
December
Living Situation (Check One)
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Live Alone
Live with Spouse
Live with Children
Live with Parents
Live with Caregiver
Other
Evacuation Information
If told to evacuate, I am not able to leave my home independently and may need assistance from emergency responders:
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Yes
No
If told to evacuate my home, I will require assistance with transportation:
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Yes
No
Describe transportation needed:
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Automobile
Van/Bus
Van/Bus with Wheelchair Lift
Medical Transport/Ambulance
I am home on oxygen requiring electricity:
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Yes
No
I will require assistance in lifting/moving life sustaining equipment:
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Yes
No
I will require evacuation to a hospital:
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Yes
No
I am dependent on a caregiver, who resides with me and understands my needs:
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Yes
No
Name and Relationship of caregiver:
Emergency Contact Information
Name of Emergency Contact (NOT living at the same address as you)
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First Name
Last Name
Relationship to you:
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Phone Number
Please enter a valid phone number.
Family Care Information
I am a member of the following Family Care Provider:
Yes
No
Which Family Care Provider:
My Choice
IRIS Program
Inclusa
Lakeland 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.
Which are you:
Applicant named on the form above
Authorized Guardian/POA for the Applicant named on the form above
Applicant Signature Authorizing Participation
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Authorized Guardian/POA Signature Authorizing Participation
Date Signing Authorization of Participation
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Month
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Day
Year
Date
Continue
Continue
Should be Empty: