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Catawba County Government


Form Section 1

Special Needs Registry Application

The purpose of the Catawba County Special Needs Registry is to provide emergency responders with important information from individuals that may require assistance during an emergency, (e.g. hurricane, flood, blizzard, power-outage and/or disease outbreak). This program is voluntary and individuals on the registry may decide whether or not to accept assistance. Completion of this form in no way ensures that the individual completing this form will receive immediate or preferential treatment in an emergency.Individuals should maintain a personal emergency plan. 

Choose one:

Who is filling out this form?
If someone else is filling out this form, please put in your contact info

Personal Information

Applicant's Full Name
Full Address
Marital Status
Living Situation
Do you need the assistance of a translator for English?
For the Hearing Impaired: Do you use sign language:
Form Section 2

Medical Information

(Check all that apply to your medical condition)

Either of these?
For the above 2 choices:

Medication Management: You are strongly encouraged to prepare an emergency kit with necessary medical supplies and to keep in that kit an updated list of necessary medications. For information on preparing an emergency kit, plese visit or

Form Section 3

Emergency Contact Information

In-State Emergency Contact
Out-Of-State Emergency Contact

Medical Provider Information (Fill in all that apply)

Home Health Care Agency ( or personal caregiver)
Respiratory Equipment Provider
Form Section 4

Transportation Information

Geographic Location
Can you, a family member or friend provide you with transportation to a shelter in an emergency?
If you need assistance with transportation, check one of the following

Pet Information*

Do you have pets that would require special attention if you were asked to evacuate your home? If so indicate the number of

*Pets may not be able to accompany you to the shelter.

Individuals are responsible for caring for the needs of an assistance animal, including bringing food and other essential needs to the shelter. Service animals are allowed in shelters but must provide proof of current rabies vaccine. 

Form Section 5

Emergency Planning

In case of an emergency, do you plan to:

Authorization Information

By submitting this form I agree or my legal guardian requests that my personal and medical information be added to the Catawba County Special Needs Registry. In the event of an emergency or disaster I hereby authorize the exchange of information between Catawba County, and the local fire department, rescue squad, or law enforcement agency and the individuals and agencies listed on this form. I grant emergency responders permission to enter my home following an emergency event or disaster situation, if necessary, to assure my safety and welfare and for the purposes of evaluating my needs.