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    Functional Needs Evacuation Registry Application- Juneau County, Wisconsin

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

    Information provided to this evacuation registry will be used by first response agencies as needed during emergency events.  Personal health information will be treated confidentially, and is not accessible to the general public.
    Enter Building Name or other location identifier to Line 2

    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

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

    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.
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