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Voluntary Emergency Preparedness Registry • Add

The Voluntary Emergency Preparedness Registry allows people with disabilities (mobility, visual, hearing, cognitive or mental health) to register in advance with the City of Worcester so that emergency workers may better plan their responses to natural and manmade disasters when ordinary support services are impaired or unavailable.

Participation in this registry is voluntary. All personal information will be kept confidential under the law, but may be shared with other emergency response agencies. Please note that providing this information does not guarantee your safety or any particular level of assistance or emergency service during a disaster; it is meant to enhance the ability of emergency responders to plan for a disaster.

You may register by completing a separate form for each person with a disability. If you need assistance filling out this form, please call (508) 799-1071. This form is for first-time registrants only; if you have already filled out this form and need to make a change, please call (508) 799-1175. If you would like to receive emergency notifications, please sign up for ALERTWorcester.

Last Name
First Name
Middle Initial
Date of Birth
Type of Residence
If Private or Public Housing, Please Select Type
If Special Needs, Please Select Residency Type
Physical Address - Number
Physical Address - Street Name
Apartment Number
Floor Level
Zip Code
Home Phone
Cell Phone
Email Address
How well do you understand the English language?
Primary Language Spoken
How many people, including yourself, are in your household?
Are you responsible for any minor children living with you?
If yes, how many?
Emergency Contact Information:
First Name
Middle Initial
Last Name
Street Address
Address 2
Zip Code
Cell Phone
Email Address
In a state of emergency may we release information to this person if they inquire about your location status?

The following information will further help us with evacuation planning:
¹Do you have a service animal?
Do you have pet(s) living with you?
What is your weight range?
Are you bed bound?
Do you walk with the assistance of
If "Other" Please Specify
Do you use a wheelchair or scooter?
If "Yes" Select Type
Do you have a sight impairment?
Do you have a hearing impairment?
Do you have a speech impairment?
In order to communicate, I use
Check All That Apply

Evacuation Transportation Needs:
Do you require transportation?
If Yes, standard transportation?
Can you slide transfer?
Do you need a vehicle with a lift?
Must be transported by ambulance?

The following information will be helpful
for your possible stay at an Emergency Shelter:
Do you have a personal emergency kit?
Medication list?
Medical supply list including account information?
File/vial of life?
Food allergies?
If "Yes" specify
Other allergies?
If "Yes" specify
Dialysis required?
If "Yes" how often?
Require bathing assistance?
Require dressing assistance?
Require eating assistance?
Require toileting assistance?
Require assistance taking medication?
Require assistance trasferring to/from bed?

Evacuation Plan:
In case of a disaster, I plan to
If evacuating to a shelter
If shelter is required, will you request an accommodation? If so, please list any specific accommodation(s)
This form was filled out by

If conditions change or this registrant no longer needs to be listed on the Voluntary Emergency Preparedness Registry, please call (508) 799-1175.

¹Only service animals are allowed in shelters. You are responsible for the care, food and other essential needs of any service animal, including animal licenses and vaccination records.

I hereby grant permission to release this information to other emergency response or human service agencies or officials. I also give local law enforcement and/or medical personnel permission to enter my home in case of an emergency.

I certify that the above information is correct and to the best of my knowledge and ability. A summary of your entry will be displayed upon submission.

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