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Emergency Management

charmeckem@charlottenc.gov

500 Dalton Avenue Charlotte, NC 28206

704-336-2412

Special Needs Registry

Release Authorization

I acknowledge that a signed release authorization form is on file at the following county location:

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Personal Information

Full Name

Sex

Contact Information

Physical Address

    Home Phone Capabilities

    Cell Phone Capabilities

    Mailing Address (if different)

      Living Situation

      Medical Information

      Conditions- Please select all that apply

      Disaster Plan

      Emergency Contact Information

      Emergency Contact Name

      Caretaker Information

      Physician Name

      Physician Address

        Pet Information

        Pet #1

        Is this pet a service animal? If yes, please explain.

        Pet #2

        Is this pet a service animal? If yes, please explain.

        Pet #3

        Is this pet a service animal? If yes, please explain.

        Pet #4

        Is this pet a service animal? If yes, please explain.