Vulnerable Population Registration
This form will be uploaded into the NC database for assisting our vulnerable populations in a time of disaster. Please be as thorough as possible, but we also understand and respect your privacy. The completion of this form serves as permission to disseminate this information only as required to render assistance to the registrant.
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What is the Registrant's Name? *
What is the Registrant's Birthday? *
MM
/
DD
/
YYYY
What is the Registrant's Approximate Weight? *
What is the Registrant's Street Address? *
What is the Registrant's Mailing Address (if different)?
What is the Registrant's Phone Number? *
Name of Subdivision, Mobile Home Park, Apartment Building if applicable
What is the Registrant's Primary Language Spoken?
What is the Registrant's Living Situation (check one)? *
What is the Registrant's Medical History? (Check and complete all that apply) *
Required
Explain any of the above conditions as needed here:
What is the Registrant's Disaster Plan? *
Emergency Contact Info (Name, phone numbers) *
Primary Care Physician or Medical Practice? (If Applicable)
Pharmacy used? (If Applicable)
Home Health Care Agency (or personal caregiver)?
Respiratory Equipment Provider? (If Applicable)
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