Register Ready NJ- Special Needs Registry

Human Services Division

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Please fill out the following information as completely as possible. Should you have any questions, or need assistance in filling out this form, please feel free to call (856) 935-7510 Ext. 8304. All information will be kept strictly private and confidential.

Why register? This allows residents with disabilities or functional needs (as well as their families, friends, caregivers and associates) an opportunity to provide emergency response agencies with information that might prove crucial during a disaster, evacuation or other emergency.

 

If you are human, leave this field blank.

Who is filling out this form?

Are you already a Register Ready NJ user and want to update your information? *

Yes

No

Unsure

Are you the person who needs assistance? *

Yes

No

If no, your relationship to the individual

Your Name *

Today's Date *

Email *

Information about the person requiring assistance

Full Name *

Date of Birth *

Phone *

Email

Physical Address *

City *

State *

Zip Code *

Use TDD/TTY?

Yes

No

Height

Weight over 300 lb?

Yes

No

Eye Color

Gender *

MaleFemale

Emergency contact information

Please provide as much contact information as possible.

Emergency Contact's Full Name *

Emergency Contact Relationship *

Emergency Contact's Phone *

Emergency Contact's Email

Emergency Contact's Address

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City

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin Islands

Zip code

Information about individual's condition or situation

This is to provide medical or emergency personnel with any information that may be vital to know in case of an urgent situation.

Evacuation Information (check all that apply) *

Must choose at least one option:

Sight Impaired

Hearing Impaired

Speech Impaired

Physically Impaired

Completely Bedridden

Requires constant skilled nursing skills

Dialysis

Dementia/Alzheimer's

Mentally/Memory Impaired

Diabetes

Developmentally Disabled

Autism Spectrum Disorder

Other Reason Needing Assistance

None

If other, please describe:

Does not:

Have access to a motor vehicle

Have a radio or television

Have a telephone

Speak English

Primary Language

Has difficulty walking and requires:

Manual Wheelchair

Motorized Wheelchair

Walker/Cane

Attendant to assist in ambulating

Hoyer lift

Requires medical equipment that is not easily transportable

Oxygen concentrator or cylinder

Ventilator

Suction Machine

CPAP Machine

BiPAP Machine

Nebulizer

Feeding Pump

Other (explain below)

Other Equipment:

Are all of the conditions resulting in the need for evacuation assistance temporary?

Yes

No

Uncertain

Do you have medications that must be taken with you if evacuated?

Yes

No

Do you have a service animal?

Yes

No

Do you have pets?

Yes

No

Do you have a 24 hour caretaker?

Yes

No

If yes, will the caretaker travel and/ or stay with you?

Yes

No

If applicable, Caretaker's First Name:

Caretaker's Email

Caretaker's Phone

Do you require evacuation assistance 24/7?

Yes

No

If No, what time do you need assistance?

Do you have any allergies?

Yes

No

What type?

Physician's Name

Physician's Phone

Pharmacist's Name

Pharmacist's Phone

Captcha *

reCAPTCHA is required.

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