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CAYUGA COUNTY DISABLED PERSONS REGISTRY In the event of a public emergency or natural disaster, some residents with special needs may require assistance during evacuations and sheltering. The Cayuga County Office for the Aging, on behalf of the Cayuga County Emergency Management Office, is updating the registration of those individuals in need. Please provide the following information: Last Name: First Name: Street Address: Apt # City / Town / Village: Zip Code: Mailing Address (if different): ( ) I live alone ( ) I live with Telephone: Cell Phone: Birth Date: Gender: ( ) Male ( ) Female ( ) Other Primary Preferred Method of Communication__________________ Local Emergency Contact Person/relationship: Home Phone: Work Phone: Cell: Back-up Emergency Contact Person/relationship: Home Phone: Work Phone: Cell: I have a hearing and/or speech impairment & need to be notified of emergencies in person. ( ) I am deaf ( ) I cannot speak & need an interpreter ( ) I have a TTY ( ) I wear a hearing aid I have a physical or mental condition which may require assistance in case of emergency. Check all that apply: ( ) Uses Wheelchair ( ) Uses Oxygen ( ) Visual Impairment ( ) Very Frail ( ) Uses Walker / Crutches / Cane ( ) Bed Bound ( ) Requires Dialysis ( ) Eyeglasses ( ) Mental Health Diagnosis ( ) Developmental Disability/Autism ( ) Seizures ( ) Alzheimer’s / Dementia ( ) Risk for Wandering ( ) Insulin Dependent Diabetes ---PAGE BREAK--- Please explain any other important information that would be helpful in an emergency: Transportation: ( ) I do not have access to any transportation ( ) I require a special vehicle (explain): ( ) I have access to my own transportation ( ) I leave my home for a portion of the year from to I hereby consent to have my name placed on the Cayuga County Disabled Persons Registry. I understand this information may be shared with appropriate emergency response personnel. By signing this form, I agree to have emergency personnel enter my residence in the event of an emergency. Signature: Date: Your information will be kept confidential and only used in the event of an emergency or natural disaster. It does not guarantee that agencies will be able to provide assistance in every type of emergency. Cayuga County shall not be held liable for any claim based on good faith failure to exercise or perform a function or duty on the part of any officer or employee in carrying out a local disaster preparedness plan. The form must be updated each year, so even if you were already on our list, please complete a new form. If you no longer wish to be included in the Registry, or you have questions, please contact us. RETURN THIS FORM TO: CAYUGA COUNTY OFFICE FOR THE AGING 160 GENESEE STREET, BASEMENT AUBURN, NEW YORK 13021 [PHONE REDACTED] [EMAIL REDACTED] Updated 10-21-21 jlt