Emergency Planning Functional Needs Identification

As part of our ongoing emergency preparedness planning, the Village of Anmore asks residents to identify any household members who may need special care in the event of a disaster or emergency. If this applies to any members of your household, please fill in this form and return it to Village Hall in a sealed envelope.

Provision of this information is 100% voluntary.
All information on this form will be kept strictly confidential by the Village, subject to the requirements of the Freedom of Information and Protection of Privacy Act.
This information will only be used by the Village in the event of a disaster or community-wide emergency.
For more information regarding this program or for assistance with enrollment, please contact the Village Hall

Applicant Information

Date

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Relationship to person requiring special care:(Required)

Information pertaining to person(s) requiring special care

Name(Required)

First Last

Enter Email Confirm Email

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Does this person live alone?(Required)

Yes

Please indicate the individual’s particular status or need:(Required)

Deaf or Hearing impairment

Blind

Mobility issues / disabled

Dementia / Alzheimer’s

Critical Illness

Mental Health

Heart Condition

Requires life saving medication (e.g. insulin)

Other (please specify in comments field below)

Comments

Please let us know what's on your mind. Have a question for us? Ask away.

By signing below, I certify that:

I understand that the information provided on this form is voluntary and will only be used by the Village to assist emergency personnel in the course of their duties.
I am solely responsible for updating this information with the Village of Anmore if changes occur.
I understand that being a participant in the Functional Needs Registry does not guarantee that I will receive emergency response services in an emergency or disaster situation.
I consent to the release of my information on the Functional Needs Registry to public health authorities, human services agencies, and emergency response agencies as necessary to provide services to me in an emergency or disaster situation.
I give local law enforcement and/or medical personnel my permission to enter this home to provide emergency services in an emergency or disaster situation, and that I have authority to grant this request.
I understand that I can withdraw my permission to participate in the Functional Needs Registry by notifying the Anmore Village Hall and that, upon receipt of such notification, the Village of Anmore will remove my information from the Registry.

Applicant's Signature(Required)

Personal information requested on this form is collected under the authority of Section 26 of the Freedom of Information and Protection of Privacy Act, as amended. The information gathered will be used to deliver or evaluate the program or activity of the Village of Anmore that is associated with this form. Questions about the collection, use, and disclosure of this information should be directed to village.hall@anmore.com