Acknowledgment:

Disaster Planning for Access and Functional Needs Program

Participation in the Disaster Planning for Access Functional Needs Program Database is voluntary. No one is required to participate. Individuals are included in the database ONLY with their permission.

Submitting your information to participate in the Disaster Planning for Access Functional Needs Program Database does not guarantee that an individual will receive immediate or preferential treatment in an emergency or disaster situation.

Individually identifiable participant information in the Disaster Planning for Access Functional Needs Program Database is confidential and will not be shared with the general public. This information will be released to public health authorities, human services agencies, and other emergency response agencies on a need-to-know basis to provide the necessary services in the event of an emergency or disaster. Aggregated non-identifiable participant information will be used and disclosed to plan for the provision of emergency and disaster services.

Participants in the Disaster Planning for Access Functional Needs Program Database may be responsible for all expenses associated with medical evacuation and shelter at a hospital or nursing facility or for any specialized equipment needed in a functional needs shelter.

By submitting this application, I hereby agree to the following terms and condition for participation in the Disaster Planning for Access Functional Needs Program Database:

• The information that I have provided in this application is correct.
• I give my permission to participate in the Disaster Planning for Access Functional Needs Program Database and to include my information in the Database.
• I consent to the release of my information on the Disaster Planning for Access Functional Needs Program Database to public health authorities, human services agencies, and emergency response agencies as necessary to provide services to me in an emergency or disaster situation.
• I give local law enforcement and/or medical personnel my permission to enter my home to provide emergency services in an emergency or disaster situation.
• I understand that being a participant in the Disaster Planning for Access Functional Needs Program Database does not guarantee that I will receive emergency response services in an emergency or disaster situation.
• I understand that as a participant in the Disaster Planning for Access Functional Needs Program Database, I may be responsible for all expenses associated with medical evacuation and shelter at a hospital or nursing facility or for any specialized equipment needed in a functional needs shelter.

I understand this information will help responders to know and understand the access functional needs and does not guarantee any particular emergency services or any level of emergency services during an emergency or disaster.

Please be as complete as possible in your responses. You will be contacted occasionally to ensure the information is correct and to make any necessary changes.

There is no substitute for personal preparation. In a disaster, government and other agencies may not be able to meet your needs. It is important for all residents to make individual plans and preparations for their care and safety in an emergency.

By submitting my information, I agree that I voluntarily authorize its release.