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McLEAN COUNTY FUNCTIONAL NEEDS REGISTRATION Revised 10/17/12 LAST NAME: _ FIRST: MI: DOB: SEX: STREET ADDRESS: APT/LOT#: CITY: ZIP: PHONE#: I REQUIRE TRANSPORTATION: Yes No Living Situation Alone with Relative Other Single Family Residence Mobile Home Apt / Condo, Complex Name: Care Taker: Hospice, Team ID: Home Health Care: Do you have a Pet? How Many/Type? Do you have a SERVICE Animal? Yes No SPECIAL NEED (CHECK ALL THAT APPLY) Kidney Disease Walker/Cane Feeding Tube Diabetes/Insulin depend Memory impaired Wheelchair assist Ventilator High Blood Pressure Seizure Bedridden Dialysis Mental health impaired Incontinence Sight impaired Speech impaired Electric dependant, Cancer Oxygen (lpm ) Geri Chair Why? Breathing treatment Deaf / Hard of Hearing Stroke Emergency Contacts: Name: Phone: Name: Phone: Prearranged: Hospital Nursing Home Alternate Living Facility Facility Name: Doctor’s Name: Phone: By signing this form I give my authorization for the medical information herein to be released only to the County Health Department, Emergency Management, Public Safety Responders and receiving facilities for the purpose of evaluating my needs and providing emergency transportation and sheltering. Records relating to registration of Persons with Functional Needs are exempt from the provisions of Public Records Law. This information contained here will be kept confidential. Signature or Representative: Date: Official use only: Transport to: General Shelter Functional Needs Shelter Hospital Source Code Register for Functional Needs Shelter Only Type of Transport: Own vehicle Van / Bus Wheelchair only Stretcher/Ambulance Fire District: Grid: Evacuation Level: Shelter Name: Comments: