NJ Register Ready (Special Needs Registry for Disasters)

Human Services Division

---

Salem County participates in the state-wide registry for residents with access and functional needs called NJ Register Ready. Register Ready is voluntary and free program designed to assist first responders and emergency planners in identifying those residents that may need assistance in evacuating in advance of an emergency and so that emergency management may develop the necessary plans to support those needs. It will also help emergency planners in the development of shelter plans for those residents with Access and Functional Needs. The information collected through a secure on-line portal is only accessible to the Salem County Health and Human Services/ Salem County Office of Emergency Management and first responders.

What is NJ Register Ready? NJ Register Ready has been established to collect information emergency responders will need to help locate and evacuate people with Access and Functional Needs during an emergency, when a family, caregiver or are unable to help them.

Who Should Register?  You (or someone on your behalf) should register if you may find it difficult to get to safety with family or friends or to a public shelter during an emergency evacuation, because of a physical or cognitive limitation, language barrier, or lack of transportation. Remember, your priority should be to relocate with a family member or friend first!

How can I submit my information? 
You can complete the online form on our site, or you can choose to register in one of the other 2 following ways:

1. Print and complete the Register Ready Form and mail it to the Salem County Health and Human Services- Attn: Jenna Hogate at 110 Fifth St. Salem, NJ 08079
2. Call 856-935-7510 extension 8304 to register by telephone. TTY/TDD translation services also available by calling TOLL FREE at 2-1-1
   –

Have questions or need assistance in completing the form?
If you have questions pertaining to NJ Register Ready, call 856-935-7510 x8304.

---

If you are human, leave this field blank.

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

Yes

No

Unsure

Who is filling out this form?

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

CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabwe

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?

Additional Emergency Information/ Comments:

Captcha *

reCAPTCHA is required.

Submit