Pender County Special Needs Registry Application For Shelter and Evacuation

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Pender County Special Needs Registry Application For Shelter and Evacuation

Last Name *

First Name *

Middle Name *

Physical Address *

City *

Zip *

State *

Mailing Address if Different

Caregiver's Name *

Emergency Contact's Name *

Relationship *

Emergency Contact Address *

Your Primary Care Physician *

Physician's Telephone *

Home Health Provider *

Primary Language *

Do you use oxygen? *YesNo

How Often Do You Use Your Oxygen? (optional) *(___ Hours per Day at ___ Rate Liters/Min)

What Type of Oxygen Do You Have? (optional)ConcentratorPortable Tank

Amount of oxygen you have on hand? (optional)

What Type of Medications Do You Take? (optional)OralSubcutaneous Injections (SQ)Intramuscular Injections (IM)Intravenous (IV)

How Mobile Are You? (optional)Bed BoundWheelchair BoundWalk with Assistance (walker, cane, another person)Walk Independently

Do You Use Any Special Medical Device? (optional)VentilatorDialysis MachineNebulizerFeeding PumpCPAP/BIPAPIV PumpSuctionOther

Are you... (optional)DeafBlindSevere Visual ImpairmentSevere Hearing LossSpeech Impairment

Do You Have Any of the Following Devices? (optional)Urinary CatheterOstomyPacemakerImplanted Pump/Catheter/Tube

What Kind of Vehicle Can You Ride In?Car/BusWheelchair Accessible VehicleAmbulance Only

Are You Mentally Handicapped? *YesNo

Do You Have a Service Animal? *YesNo

Please List Any Additional Information You Think Necessary To Your Care Below: (optional)0 / 180

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Notices

Nondiscrimination Statement
March 6, 2019
ATENCIÓN BENEFICIARIOS DE MEDICAID: AVISO DE SUS DERECHOS BAJO HAWKINS v. COHEN
March 1, 2019
ATTENTION MEDICAID BENEFICIARIES: NOTICE OF YOUR RIGHTS UNDER HAWKINS v. COHEN
March 1, 2019
Opioid Overdose: Understanding the Epidemic
January 16, 2018
Pender County Resource Guide
September 7, 2017

See All Notices

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SPECIAL NEEDS REGISTRY FORM

Please click the above icon (or here) for Pender County’s Special Needs Registry Form!

CodeRed

Pender County is pleased to announce our new Emergency Notification System, CodeRed.
CodeRed enables the Pender County Office of Emergency Management on alert the citizens, of Pender County, of any impending emergency situations in their area.

Please use the button below to Opt-In (register) for this service. In addition, you may also logon to your account if you have already registered.

Nondiscrimination Statement

ATENCIÓN BENEFICIARIOS DE MEDICAID: AVISO DE SUS DERECHOS BAJO HAWKINS v. COHEN

ATTENTION MEDICAID BENEFICIARIES: NOTICE OF YOUR RIGHTS UNDER HAWKINS v. COHEN

Opioid Overdose: Understanding the Epidemic

Pender County Resource Guide

Health & Human Services

Phone Numbers