Voluntary Emergency Preparedness Registry

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.

Last Name
First Name
Middle Initial
Suffix
Date of Birth
Gender	Male Female
Type of Residence	Private Special Needs Public Housing
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
City
State
Zip Code
Home Phone
Cell Phone
TDD/TTY
Email Address
How well do you understand the English language?	Well Not Well None
Primary Language Spoken
How many people, including yourself, are in your household?
Are you responsible for any minor children living with you?	Yes No
If yes, how many?	Emergency Contact Information:
First Name
Middle Initial
Last Name
Street Address
Address 2
City
State
Zip Code
Phone
Cell Phone
Email Address
In a state of emergency may we release information to this person if they inquire about your location status?	Yes No The following information will further help us with evacuation planning:
¹Do you have a service animal?	Yes No
Do you have pet(s) living with you?	Yes No
What is your weight range?	Less Than 300 lbs. More Than 300 lbs.
Are you bed bound?	Yes No
Do you walk with the assistance of
If "Other" Please Specify
Do you use a wheelchair or scooter?	Yes No
If "Yes" Select Type	Manual Wheelchair Motorized Wheelchair Scooter
Do you have a sight impairment?	None Glasses/Contacts Blind
Do you have a hearing impairment?	None Hearing Aid Deaf
Do you have a speech impairment?	None Moderate Significant
In order to communicate, I use
Check All That Apply	Use Oxygen Use Feeding Tube Use Ventilator Use Suction Unit Use Respirator Use Prosthetic Mental Health Condition Cognitive Impairment Alzheimer/Dementia Developmental Disability Evacuation Transportation Needs:
Do you require transportation?	Yes No
If Yes, standard transportation?	Yes No
Can you slide transfer?	Yes No
Do you need a vehicle with a lift?	Yes No
Must be transported by ambulance?	Yes No The following information will be helpful for your possible stay at an Emergency Shelter:
Do you have a personal emergency kit?	Yes No
Medication list?	Yes No
Medical supply list including account information?	Yes No
File/vial of life?	Yes No
Food allergies?	Yes No
If "Yes" specify
Other allergies?	Yes No
If "Yes" specify
Dialysis required?	Yes No
If "Yes" how often?
Require bathing assistance?	Yes No
Require dressing assistance?	Yes No
Require eating assistance?	Yes No
Require toileting assistance?	Yes No
Require assistance taking medication?	Yes No
Require assistance trasferring to/from bed?	Yes No 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	Self Family Member Caregiver Other
*Captcha
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.

Voluntary Emergency Preparedness Registry • Add