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Special Needs Registry Sign-Up

  1. Acceptance

    The Iredell County Special Medical Needs Registry gives key information to emergency workers in the event of a 911 call and/or during a disaster such as a hurricane, flood, winter storm, power outage, disease outbreak or nuclear event, etc. Persons on the registry are volunteering for the list and have the choice to agree to, or say no to, assistance. Filling out this form does not guarantee the signed up person will receive immediate or special aid in an emergency or disaster. People should always have their own emergency plan in place. This registry allows Emergency Service Providers (emergency management, fire departments, law enforcement, Public Health, etc.) to share this information with one another to help with your recovery. All records are kept confidential. You will receive a phone call or mailing at least every other year to update your information. If your health condition or personal information changes before the scheduled update, please contact Iredell County Emergency Management at 704-878-5353 to change your information in the registry. Your information will be checked at least every other year. If Iredell County Emergency Management cannot reach you after three attempts during the update, your information will be deleted from the registry.

  2. Eligibility

    Eligible people for the list must live in Iredell County AND have at least one of the following: • Have to have help with daily living actions (dressing, bathing, toileting, etc.) • Have need of medical observation or aid • Have a constant or lasting, or easily spread sickness (Tuberculosis, Dementia, etc.) • Disability and/or homebound • DO NOT live in a long term facility (Nursing Home, Assisted Living, or Care Home)

  3. EPZ

    Select if you know you live within the 10-Mile Emergency Planning Zone of McGuire Nuclear Station. If unsure, leave blank.

  4. Need Transport

    Select if you will need transportation to a shelter should the need to evacuate your residence arise.

  5. Disclaimer*

    I understand that completing this form and including my information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry DOES NOT create a contract for services. Neither the entities or individuals that have created or maintained this registry or collected information for this registry, nor any entity or individual that may utilize the information contained in the registry including but not limited to, Iredell County Emergency Management, the Department of Public Safety, Division of Emergency Management, Public Health authorities, human services agencies, emergency personnel and volunteers, warrant that assistance will be provided to you during an emergency or disaster. I understand that participation in this registry is voluntary and this it is my duty and responsibility to update my information on this registry. By completing this registration form and including the information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry, I hereby confirm and attest that the information provided in this registration is correct and that should the information that I have provided change, I will promptly update the registry. By completing this registration form and including the information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry, I also hereby warrant that the information has been provided voluntarily and that if I have required assistance to complete this form that I have consented to the assistance provided. By completing this registration form and including the information in the Iredell County Special Needs Registry and State Special Needs Registry, I also hereby waive any and all claims which relate to the collection, maintenance or use of the information I have supplied which may be asserted against the entities or individuals that have created or maintained this registry or collected information for this registry and any entity or individual that may utilize the information contained in the registry including but not limited to the Department of Public Safety, Division of Emergency Management and emergency personnel and volunteers. I understand that my participation in the Iredell County Special Medical Needs Registry and State Special Needs Registry is voluntary and that all information I provide, including any Protected Health Information, will be treated as confidential, but that under some limited circumstances the information may be released without my permission as allowable by federal or state law. I further understand that the information I provide will only be released to the Department of Public Safety, Division of Emergency Management, the County of Iredell and Public Health authorities, human services agencies, emergency responders, managers and planners, and those individuals who manage the Registry database. I understand that the information I have provided to the Registries will only be used in the following circumstances: to respond to disaster-related events; to respond to emergency needs; for evacuation and recovery efforts; and for disaster planning purposes. I understand that under some limited circumstances the information may be released without my permission as allowable by federal or state law. YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION I understand that I, or my personal representative, is entitled to receive a copy of the completed authorization form upon request. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke the authorization I must do so in writing and submit my written revocation to Iredell County Emergency Management. I understand that the revocation will not apply to information that has already been released. I also understand that once information is released to others, it may be re-disclosed to individuals or organizations not subject to state and federal privacy and confidentiality laws and may not be protected. I have had full opportunity to read and consider the contents of this Authorization. I understand that, by signing this form, I am confirming my authorization that the Department of Public Safety, Division of Emergency Management may disclose to the person(s)/organization(s) named in this form the information described in this form. I certify that the above information is correct. I hereby authorize the Department of Public Safety, Division of Emergency Management, to release, use or disclose this information to other emergency response or human service agencies or officials and to include this information in the State Special Needs Registry. I also give law enforcement permission to enter my home in case of an emergency. I understand that I have the right to revoke this permission by notifying Department of Public Safety, Division of Emergency Management and asking that my name be removed from the special needs registry.

  6. Leave This Blank:

  7. This field is not part of the form submission.