Section 1 of 9 in this document
Special Needs Registry
Release Authorization
I acknowledge that a signed release authorization form is on file at the following county location:
Catawba County (NC)
Gaston County (NC)
Iredell County (NC)
Lancaster County (SC)
Lincoln County (NC)
Mecklenburg County (NC)
York County (SC)
Sign Here
Sign Here
First Name
Last Name
Email
Choose how to sign
Draw
Type
I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.
Section 2 of 9 in this document
Personal Information
Full Name
First Name
*
Initial
Last Name
*
Sex
Male
Female
Weight
Height
Section 3 of 9 in this document
Contact Information
Physical Address
Address or Location
Home Phone Number
Home Phone Capabilities
Text Capable
TDD Capable
Cell Phone Number
Cell Phone Capabilities
Text Capable
TDD Capable
Email
Mailing Address (if different)
Address or Location
Living Situation
Live Alone
With Children
With Spouse/Significant Other
With Pets
With Parents
Other (explain below)
Language
*
Choose One
African languages
American Sign Language
Arabic
Chinese
Dravidian
English
French
German
Greek
Hindi and related
Italian
Japanese
Korean
Spanish
Vietnamese
Other
Section 4 of 9 in this document
Medical Information
Allergies
*
Conditions- Please select all that apply
Ambulatory with Walker
Ambulatory with Wheelchair
Bedridden
Contagious Disease
Developmentally Disabled
Dialysis
Gastric Feeding Tube
Hearing Impaired
Insulin Dependent
IV Medication
Medications (list and explain below)
Memory Impaired (list and explain below)
Mental Heath Condition (list and explain below)
Ostomy Care
Oxygen Concentrator or Ventilator - Continuous
Physically Disabled (explain below)
Oxygen Concentrator or Ventilator - Intermittent
Portable Oxygen Tank
Refrigeration Needed for Medication
Require Life-Sustaining Equipment
Seizures
Special Dietary Needs (explain below)
Speech Impaired
Suction Machine
Vision Impaired
Other (explain below)
Medications
Mental Health
Memory Impaired
Physically Disabled
Special Dietary Needs
Other Conditions
Section 5 of 9 in this document
Disaster Plan
Section 6 of 9 in this document
Emergency Contact Information
Emergency Contact Name
First Name
Last Name
Emergency Contact - Work Phone
Emergency Contact - Home Phone
Emergency Contact - Cell Phone
Section 7 of 9 in this document
Caretaker Information
Physician Name
First Name
Last Name
Physician Phone Number
Physician Address
Address or Location
Pharmacy Name
Pharmacy Phone Number
Home Healthcare Agency or Personal Caregiver (if applicable)
Home Healthcare Agency or Personal Caregiver Phone Number
Respiratory Equipment Provider (if applicable)
Respiratory Equipment Provider Phone Number
Section 8 of 9 in this document
Pet Information
Pet #1
Name
Type
Age
Is this pet a service animal? If yes, please explain.
Yes
Pet #2
Name
Type
Age
Is this pet a service animal? If yes, please explain.
Yes
Pet #3
Name
Type
Age
Is this pet a service animal? If yes, please explain.
Yes
Pet #4
Name
Type
Age
Is this pet a service animal? If yes, please explain.
Yes
Other Pets/Details
disregard this