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. 

Personal Information

Form Section 2

Medical Information

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 www.ready.gov or www.RedCross.org.

Form Section 3

Emergency Contact Information

Medical Provider Information (Fill in all that apply)

Form Section 4

Transportation Information

Pet Information*

*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

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.