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I WANT TO...
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.
*
Indicates required field
Name
*
First
Last
Date of Birth
*
Primary Phone Number
*
Alternate Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Enter Building Name or other location identifier to Line 2
Township
*
Email
*
Application Status
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New Application
Update Application
Application Date
*
Emergency Contact Information
Emergency Contact Name and Phone Number
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Additional Emergency Contact Name and Phone Number
*
Evacuation Information
I require SPECIALIZED vehicle transportation to a shelter in an emergency.
*
Yes
No
I need the use of these vehicle options
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Bus or Van with Wheelchair Lift
Ambulance
Bariatric Transport
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.
*
Wheelchair Bound
Bedridden
Use walker, canes, or crutches
Hearing Impaired
Vision Impaired
No Physical Limitations
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
Additional Functional or Physicial LImitations Comments
*
Preparation
It
is recommended to be enrolled in the Juneau County CODE RED Emergency Notification program to receive the earliest possible evacuation notice.
The CODE RED community notification system will send me alerts concerning time sensitive and/or emergency information that will impact my area so I may start my personal emergency plan. I wish to receive these notifications.
*
Yes
No
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.
Authorized by
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First
Last
Choose One
*
Applicant
Authorized Guardian
Acknowledge and Agree
*
Yes
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.
Submit