Registry - Options For Independence

CAYUGA COUNTY
DISABLED PERSONS VOLUNTARY REGISTRY

DO YOU HAVE SPECIAL NEEDS??

In the event of a public emergency or natural disaster, some residents may need special assistance during evacuations and sheltering because of physical or mental handicaps. The Cayuga County Health & Human Services Office on behalf of the Cayuga County Emergency Management Office is compiling a VOLUNTARY registration list of those individuals who may need assistance.

The purpose of this information is to make the Cayuga County Emergency Management Office aware of those with special needs. THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND WILL BE USED ONLY IN CASE 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 liable for any claim based upon the 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/emergency plan.

To register in the Cayuga County Disabled Persons Voluntary Registry, fill out and submit the on-line form below over the Web. Or, download the Registry Form in Adobe Portable Document Format, to print and mail into the Cayuga County Health & Human Services Department. Please note, in order to download this form, you must have Adobe Acrobat Reader installed on your computer. If you do not have this software, click on the Adobe icon to download a free copy now.

PLEASE NOTE: Your browser must be able to support "forms" (eg. Netscape, Explorer, Lynx). If you are using some other browser, please e-mail your membership request with all the information below to:

options@optionsforindependence.org

Step 1: Your Info

Your Name:

Your Phone Number:

Address: (Include Apt., City, State and Zip)

Municipality in which you live: (Name of Town, Village or City)

Date of Birth:

Other Info:

Pets: Yes No
If Yes, how many? and what kind

Check all that apply:

I have a hearing and/or speech problem and need to be notified in person.

I have a TTY (Teletypewriter).

I have a medical disability which may require assistance in case of an emergency (check all that apply):

I leave the state for a portion of the year from to

Step 2: Contact Persons

Local Contact Person:

Name:

Releationship:

Home Phone:

Work Phone:

Out of State Contact Person:

Name:

Releationship:

Home Phone:

Work Phone:

Step 3: Disclaimers

I hereby consent to have my name placed in the Cayuga County voluntary registry of disabled persons, including periodic updates.

The undersigned realizes that Cayuga County cannot guarantee or ensure that any officer, employee, agent or volunteer shall properly perform a function or duty in carrying out a local disaster/emergency plan and therefore waives any and gall claims against Cayuga County for such the failure of anyone to exercise or perform such a function or in the event such a function is performed negligently.

Yes I Agree No I Do Not Agree

I hereby consent and pre-authorize that the emergency response personnel shall be able to enter my home during search and rescue operations if necessary to assure my safety and welfare during an emergency or natural disaster.

Yes I Agree No I Do Not Agree

Step 4: Submit

If you have filled out this form completely and agree with both disclaimers, you may press the "Submit" button to send this form. If you would like to clear this form and start over, please press "Reset". If you would like to exit this form with out submitting any information, please press "Exit".

EXIT without submitting any information.