Access & Functional Needs Registry

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The Access & Functional Needs Registry is a resource to assist residents who have physical, medical, or functional disabilities that would place them at higher risk during an emergency event. Individuals on the Access & Functional Needs Registry will be contacted by a trained volunteer 72 to 36 hours before an emergency is expected to affect our area. The volunteer will review the applicant’s Personal Disaster Plan and notify the staff if additional assistance is needed.

The Access & Functional Needs Registry is not intended for individuals who live in assisted living or long-term care facilities, residential treatment facilities, or those who have comprehensive healthcare services, such as home health agencies, enrollment with Intellectual and Developmental Disabilities (IDDs) program, Community Alternatives Program for Disabled Adults (CAP/DA), CAP/C for children, etc. These providers are required by law to have plans in place to take care of their residents and clients in the event of an emergency.

After the participant registers, they will remain on the Access & Functional Needs Registry in perpetuity until a request is made to remove the participant from the Access & Functional Needs Registry, staff has encountered multiple failed attempts to connect, the participant moves outside the county, the participant is deceased, or notification is provided of a status change. There is no need to register more than once.

Your information will remain confidential. New Hanover County will not share, distribute or sell your information.

I acknowledge that I am authorized to complete this form and am not acting on behalf of a third party.

Do you have a Legal Guardian?

Personal Information

Last Name

First Name

M.I.

Date of Birth

Gender Identity

Gender

Race

Ethnicity

Preferred Language

Race (Other)

Ethnicicity (Other)

Language (Other)

Address Information

Street Address

Apt./Unit

City

State

Zip Code

Living Arrangements

Residence Type

Living Arrangements (Other)

Residence Type (Other)

Personal Contact Information

Preferred Phone

Backup Phone

Video/TTY Phone

Preferred Communication

Email Address

May we share your information with 911 and Emergency Responders?

YesNo

Emergency Contact Information (Primary)

Primary Contact Name

Relationship

Preferred Phone

Work Phone

Alternate Phone

Email Address

Street Address

Apt./Unit

City

State

Zip Code

Do you have an additional Emergency Contact?

YesNo

Emergency Contact Information (Secondary)

Secondary Contact Name

Relationship

Preferred Phone

Work Phone

Alternate Phone

Email Address

Street Address

Apt./Unit

City

State

Zip Code

Medical Provider Information:

Primary Physician:

Primary Physician Phone:

Pharmacy:

Pharmacy Phone:

Oxygen Provider:

Oxygen Provider Phone:

Home Health Agency:

Home Health Agency Phone:

Agreement to Terms of Use & Information Release

Terms of Use: It is your responsibility to verify your contact information with the New Hanover County Access & Functional Needs Registry at least annually. If we are unable to reach you, you will be removed from the Access & Functional Needs Registry. Citizens utilize the services of the Access & Functional Needs Registry at their own discretion. The Access & Functional Needs Registry; Individual Care Coordination Center (IC-3); health care facilities; and adult care homes, acting in good faith, are permitted to waive certain rules to provide temporary shelter or services during disasters and emergencies. Temporary sheltering facilities; IC-3; and the Access & Functional Needs Registry staff and volunteers are not liable for providing care. A personal caregiver is required during periods of temporary placement.

I agree with this statement.

I certify that the above information is correct. I hereby grant permission to New Hanover County Department of Emergency Management and the Senior Resource Center Retired & Senior Volunteer Program (RSVP) and volunteers working under the direction of these agencies to use this information for the following purposes ONLY: (1) to include my name/information in the county’s Access & Functional Needs Registry; and/or (2) to give to emergency response agencies for assistance with evacuation or aid in the event of a disaster or emergency. This information is confidential. My participation in the Access & Functional Needs Registry is voluntary.

I agree with this statement.

Electronic Signature

Full Legal Name

Initials

Date of Form Submission

Oxygen	Feeding Pump	Suction	Dialysis
Ventilator	Nebulizer	Other

Deaf	Hard of Hearing	Speech-Impaired
Forgetful	Non-Verbal	Other

Bedridden	Wheelchair	Prosthetic	Walker
Cane	Other