Functional Needs Registry

What Is The Functional Needs Registry?
Click here for a full description of the program.
Disclaimer

The purpose of the Flathead County Functional Needs Registry is to provide emergency responders in Flathead County with important information from individuals that may require assistance during an emergency, such as tornado, flood, blizzard, and power outage or disease outbreak. This program is voluntary and in no way ensures that the individual completing this form will receive immediate or preferential treatment in an emergency. This program will merely provide the emergency response community with information that is pertinent to developing an effective response. The Flathead County Functional Needs Registry in no way replaces the responsibility of individuals to have their own emergency plan.

Filling out this form is strictly voluntary and the data will be kept strictly confidential. It will be available only to local emergency assistance officials. Please provide all information as completely as possible.

NOTE: If you have already submitted a registration through this website and need to make changes to it, please contact us with your changes instead of submitting a new form.

Personal Information
First Name:
Last Name:
Initial:
Birth Date:
Gender:
Street Address Number: ?If your address is 100 Main, the "100" would go into this field
Address Number Suffix: ?Used for addresses such as: 100 Main Street
Unit Type: ?If your home is an upper unit, suite, apartment, etc. select that here
Unit Prefix: ?If your unit number is A1, the "A" would be selected here
Unit Number: ?If your unit number is A1 or 1A, the "1" would go into this field
Unit Suffix: ?If your unit number is 1A, the "A" would be selected here
Street Address Prefix:
Street Name:
Street Address Type:
Street Address Suffix:
Subdivision, Mobile Home Park, Apartment Building, etc:
City:
Zipcode:
Home Phone:
Cell Phone (w/ area code):
Msg. Phone (w/ area code):
Do You Use a Relay Service or Other Communication Method?   Yes     No Other Communication Method(s) Used:
Email Address:
Primary Language:
Understand English? Yes No
Read English? Yes No
Write English? Yes No
Living Situation:
Live Alone With Spouse With Children With Parents
Group Home Other (Explain):  
In total, how many people live in your household?
Type of Residence:
House Mobile Home Apartment Assisted Living Facility
Senior Housing Complex/Facility Homeless Shelter
Is there an elevator at your residence?
Yes    No
Winter resident only?
Yes    No
Summer resident only?
Yes    No
Emergency Plans
Do you have an emergency plan to ensure your safety during different types of emergencies? Yes No
Do you have emergency supplies on-hand to last up to 3 days? Yes No
Do you have access to information and communication devices that would notify you of an emergency? Yes No
Do you have out-of-town contacts? Yes No
Do you have a backup power supply for essential medical equipment? Yes No
If evacuation is required, do you plan to:
    Evacuate to a public shelter? Yes No  
    Evacuate to home of family/friends? Yes No  
    Evacuate to another location? Yes No Please Specify:
What are your personal needs, and resources available to meet those needs in the event of an emergency?
Needs
Resources
Transportation
Can you, a family member, friend or care giver provide you with transportation to a shelter in an emergency?
Yes    No
If you need assistance with transportation, check one of the following:
Automobile Van with wheelchair lift
Bus Medical transport required
Type of Functional Need
Hearing Impaired Communication Assistance Needed? Yes No
Visually Impaired Guidance Assistance Needed? Yes No
Speech Impaired Communication Assistance Needed? Yes No
Physically Impairment Mobility Assistance Needed? Yes No
Developmental Disability
Mental Illness
Non-English Speaking
Low Literacy
Without Transportation to a Safe Destination
Isolated Populations
Homeless
Medical Information (please check all that apply to your condition)
Advanced Alzheimer's Disease
Advanced Dementia
Allergies (please specify):

Anxiety or Depression
Assistance with Bathing
Assistance with Dressing
Assistance with Use of Toilet
Autism
Bladder Dysfunction
Bowel Dysfunction
Catheter
Chemotherapy
Colostomy
Conduct Disorder
G or J Tube Feeding
Hospice Care
Insulin (refrigerated)
Insulin (non-refrigerated)
IV Therapy
Medication Management
Suctioning
Tracheotomy Tube
Unstable Cardiac Condition
Unstable Pulmonary Condition
Unstable Seizures
Weight Over 300 Pounds
Wound Dressing Changes
Other (please indicate):

Medical condition is:
    Temporary
    Permanent
 
If temporary, condition is related to:
    Surgery
    Accident or Injury
    Pregnancy
Are you dependent on any of the following?
Apnea Monitor
CPAP
Electricity - Intermittent
Electricity - Continuous
Oxygen:
         Hours Per Day:
        Portable Tank
        Concentrator
Nebulizer
Dialysis
Special Diet
Ventilator
Pacemaker or Related
Prescription Meds
Other Medical Equipment (please specify):
Mobility
Can you get around by yourself? Yes No
Can you climb stairs? Yes No
Motorized scooter/wheelchair? Yes No
Can you transfer to/from wheelchair by yourself? Yes No
Do you need a walker? Yes No
Do you need a cane? Yes No
Can you get around with assistance? Yes No
Are you confined to a bed? Yes No
Wheelchair (non-motorized)? Yes No
Need a wheelchair lift/ramp? Yes No
Do you need crutches? Yes No
Do you need a white cane? Yes No
Service Animals and Pets
Do you have a service animal? Yes No
Do you have other pets? Yes No
     # Cats: # Dogs:
Service animal weight in pounds:
Have a pet emergency plan? Yes No
Other (types of pets and number):
Emergency Contact Information
Name:
Day Phone:
Address:
Evening Phone:
Relationship to You:
Cell Phone:
Email Address:
Care Giver Information
Name:
Day Phone:
Address:
Evening Phone:
Relationship to You:
Cell Phone:
Email Address:
Will caregiver accompany you to a shelter?          Yes      No
Medical Provider Information
Physician 1 Name:
Office Phone 1:
Physician 1 Address:
Physician2 Name:
Office Phone 2:
Physician 2 Address:
Physician 3 Name:
Office Phone 3:
Physician 3 Address:
Dialysis or Other Similar Medical Treatment Center
Name of Facility:
Day Phone:
Address:
Evening Phone:
Contact Person:
Medical Equipment Provider
Name:
Day Phone:
Address:
Evening Phone:
Contact Person:
Home Health/Hospice Care Provider
Facility Name:
Day Phone:
Address:
Evening Phone:
Contact Person:
Pharmacy
Name:
Day Phone:
Address:
Evening Phone:
Pharmacist:
List of Medications
Prescription Dosage Schedule
Additional Comments
By submitting this form, I (or my legal guardian) agree that my name be added to the Flathead County Functional Needs Registry. I give Flathead County authorization to share this information with other community emergency responders, only in the event of an emergency, in order to facilitate an effective response. I grant emergency responders permission to enter my home following an emergency or disaster situation, if necessary, to assure my safety and welfare.
Signed and Submitted By (your name):
I am the:
Applicant          Legal Guardian