SPECIAL NEEDS "ON-LINE" REGISTRATION FORM

Below you will find our on-line registration form.  You can fill this form out yourself, or you may have someone fill this form out for you on your behalf.  Please provide as much information as possible to help us better serve you.  Be certain to provide contact information, as we will need to confirm this information before you can be entered into our Project Special Response-Special Needs Registry.

Questions with an asterisk* are required.  This confidential information is used solely by the Anderson County 911 Central Communications Center for emergency preparedness and response.

Title *	----Mr.Mrs.MissMs.Dr.Reverend.
First Name *
Last Name *
Middle Initial
Date of Birth (MM/DD/YYYY) *
Street Address: *
Street Address (line 2)
Apartment/Unit (if applicable)
City *
Zip Code *
Your Home Phone Number (if applicable)
Your Cellphone Number (if applicable)
Email Address, if applicable
Marital Status *	----MarriedDomestic PartnerSingle/Separated/DivorcedWidow/Widower
Do you Live Alone? *	Yes  No
Do you have fmaily/friends nearby? *	Yes  No
Name of Emergency Contact: *
Is English your primary language? *	Yes  No
If the answer is NO above, please indicate what is the primary language:
Do you have a Caregiver? *	----I have no CaregiverHave Part-time CaregiverHave Full-time Caregiver
Phone Number of Emergency Contact:
Please Check what medical conditions apply: *	Wheelchair  Bed Ridden  Use Walker  Other Mobility Issue  On Dialysis  Vision Impaired  Blind  Have Service Animal/Guide Dog  Deaf or hearing impaired  Uses Sign Language  On Oxygen  Use Ventilator/Respirator  IV Support  Type I Diabetic  Type II Diabetic  Uses Insulin, or Insulin Dependent  Other
If other from above, please list other health conditions:
Name of person filling out this form, if other than yourself
If form was filled in by someone else, what is the relationship of that person?	----SpouseDomestic PartnerParentChildGrandchildCaregiverClergyFriendOther
If Other from above, what is the relationship?
Email Address of person filling out this application, if other than yourself, and if applicable.
Is there any additional information that would be helpful to emergency responders?
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