Functional Needs Form

The purpose of the Functional Needs Evacuation Registry is to provide Emergency Responders in your municipality with important information from individuals who may require EVACUATION ASSISTANCE during an emergency, such as tornado, flood, blizzard, power outage, or disease outbreak.

Juneau County is committed to making good use of the information you are providing to enhance efforts to protect you in an emergency. However, naturally, there can be no guarantee of your safety by the County, which is always primarily your responsibility.

Address *

Line 1

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City

State

Zip Code

Country

Emergency Contact Information

Evacuation Information

Functional or Physical Limitations that impact my evacuation.
Answer each limitation section. If the section does not apply to your condition, choose the NO option for the section.

I have physical limitations, which are the reason(s) I may need evacuation assistance in an emergency. *

I have respiratory limitations, which are the reason(s) I may need evacuation assistance in an emergency. *

Portable Oxygen or Oxygen Concentrator use Ventilation Dependent Suction required to keep my airway open Frequent CPAP use (not just at bedtime) No Respiratory Limitations

I have functional limitations, which are the reason(s) I may need evacuation assistance in an emergency. *

Developmental Disability Social Impairment Psychological Impairment No Functional Limitations

I have communication limitations, which are the reason(s) I may need evacuation assistance in an emergency. *

English is not my first language Speech Impaired Comprehension Impaired No Communication Limitations

Preparation

It is important to be enrolled in the Juneau County CODE RED Emergency Notification program to receive the earliest possible evacuation notice.

Look on the Emergency Management page for information on personal and family evacuation planning measures.

Authorization

I (or authorized guardian) agree that my information will be added to the Functional Needs Evacuation Registry. I give my municipality and Juneau County Emergency Management authorization to share this information with community emergency responders in the event of an emergency to facilitate an effective evacuation. I grant emergency responders permission to enter my home during or following an emergency event or disaster situation if necessary to assist with my safety and welfare.

By checking Yes above, you are acknowledging and agreeing to the Authorization set forth above. Checking the box is the equivalent of an electronic signature signifying your assent and approval.

Functional Needs Evacuation Registry Application- Juneau County, Wisconsin

Emergency Contact Information

Evacuation Information

Functional or Physical Limitations that impact my evacuation. Answer each limitation section. If the section does not apply to your condition, choose the NO option for the section.

Preparation

Authorization

Functional or Physical Limitations that impact my evacuation.
Answer each limitation section. If the section does not apply to your condition, choose the NO option for the section.