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715 NW Dimmick Street
Grants Pass, OR 97526
Phone: (541) 474-5325
Fax: (541) 474-5353
Contact: Diane Hoover, PhD, FACHE
Email: publichealth@co.jo. . .
Hours: 9:00 - 4:30 PM Mon-Th (Closed 12-12:30 for lunch), and Closed Fridays, WIC 8:00-5:15M-Th (Closed for lunch 12:30-1:00pm), Closed Fridays
Disaster Registry

 

 

 

 

 

Jackson and Josephine

Counties, Oregon

 

Would you need special help in an emergency?

 

 

You might want to apply to be in the Disaster Registry if--in the case of a flood, forest fire or other disaster--you or someone you care for would:               

                                                                                     

·        Need outside help to safely leave your home during a disaster;

·        Be in jeopardy if you stayed in your home, without assistance, for three days;

·        Need special notification about the need for evacuation, due to impairment.

                            

The Disaster Registry provides the names and locations of people who need special assistance to fire, police, health and rescue workers during disasters.  Being on the Disaster Registry does not guarantee that you’ll get help first in a disaster. There are so many needs during a disaster, that our firemen and police can’t help everyone at once.  But if your name is in the Disaster Registry, they will know of your need for special assistance. 

Please remember:  even if you are on the Disaster Registry, you should call 911 if you find yourself in a life-threatening situation.

 

If you want to be on the Disaster Registry, or if you want someone for whom you are legally responsible to be on it, please complete and sign the attached form. Once we receive your application, it may take three months or more for your information to be available to rescue workers.

 

After completing the registration form, please keep this letter for your records.

 

 

You may also register on-line

at www.rvcog.org

 

 Animal Shelter Preparedness

 

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Be Prepared  yourself!  Remember:  whether a person stays at home during a disaster or goes to a shelter, there are certain steps he or she can do to prepare.  For instructions about creating a “72-hour Kit” for use if you must stay at home, see your county’s Family Emergency Preparedness Handbook.  You can pick up a free copy from your local county or law enforcement office.                     

 

If you are a person who has special needs because of a disability you should make a list ahead of time of items to be packed quickly in case you must leave your home if there is a disaster.  Keep a backpack or small suitcase available to pack on short notice, if necessary, with a list, customized to your needs, similar to the one below:

 

·        Personal hygiene items and a change of clothing

·        An extra set of keys for your house and car

·        Cash, a credit card, and change for a pay phone

·        Your insurance agent's name and phone number

·        Special needs such as eyeglasses, hearing aid batteries, incontinence supplies,

·        walker, cane, wheelchair–all labeled with your name and phone number

·        A copy of your health information card

·        A few days worth of essential medications and, if you use it, cylinders of oxygen or

·        other essential supplies.

 

You will be contacted by us on a quarterly basis to make sure your information is current.

 

If you have any questions about the Disaster Registry, please call Senior & Disability Services of Rogue Valley Council of Governments at (541) 664-6674.

Please complete and return the attached application form to:

SDS RVCOG, P.O. Box 3275, Central Point, OR 97502.

 

PLEASE DATE AND KEEP THIS NOTICE FOR YOUR RECORDS

 

Date of application__________________

                                                                                                                                                                                                                                                                                                                                                                                   

 

                       


                                      

                                  Jackson and Josephine Counties, Oregon

1/11 ver.

                                                                             Application

Date___________

Name:                 Last____________________________ First____________________________

Street #____________    N S E W______  Street______________________    ST LN RD_____   Apt/Sp #______

                                       

City_______________    ZIP___________

County____________________________________                          Gender_________

Mailing Addr_____________________________________________________________________________

Phone_______________________   E-Mail_____________________________________________________

Cell Phone___________________                 Birthdate___________________

Is House number visible from the Street? Y/N____                   Is this a Care Facility? Y/N____

  Apt/Mobile Park           Name__________________________________________________

Apt/Mobile Park   St Address___________________________________________________

           Special Needs that affect my ability to help myself in an emergency:

Mobility Impairment?        Y/N____          Describe_______________________________________________

Hearing Limitations?        Y/N____           Describe_______________________________________________

Vision Limitations?           Y/N____           Describe_______________________________________________

Use Oxygen?                   Y/N____          Describe_______________________________________________

Speaking Difficulty?         Y/N____          Describe_______________________________________________

Mental Health?                Y/N____           Describe_______________________________________________

Medical Equip?                Y/N____           Describe_______________________________________________

ME Needs Eliectric?        Y/N____           Describe_______________________________________________

Dialysis?                          Y/N____           Describe_______________________________________________

Other Condition?             Y/N____           Describe_______________________________________________

Speak English?               Y/N____            Language______________________________________________

Service Animinal?           Y/N____            Type__________________________________________________

Cooperative Under Stress? Y/N____            Memory/ Concentration  Problems? Y/N____

                                                                   I need to take medications with me. Y/N____

Medical and ___________________________________________________________________________

  other Notes 

                      ___________________________________________________________________________

 

                      ___________________________________________________________________________


                                                                       

 ID #_____              NAME_________________________________________

  Caregiver Information

Require a Caregiver?  Y/N____

Caregiver_____________________________________    Relationship?___________________

Mail To________________________________________________________________________________

Phone______________________    Cell__________________  E-mail_______________________________

  Emergency Contact Information:  Guardian, Family Member

EC 1 Name____________________________________  Relationship? ___________________

Mail To________________________________________________________________________________

Phone______________________    Cell__________________  E-mail_______________________________

EC 2 Name_________________________________Relationship? ___________________

Mail To________________________________________________________________________________

Phone______________________    Cell__________________  E-mail_______________________________

 Do you use any of the following services?  Please note all that apply

Senior Disability Svc?      Y/N____        Contact___________________________   Phone________________

Medical Equip Co?           Y/N____         Name___________________________    Phone________________

Develop Disability Svc?    Y/N____       Contact___________________________   Phone________________

DHS Self Suffic/Chld Welf? Y/N____        Contact___________________________   Phone________________

Medical Doctor?               Y/N____       Doctor____________________________   Phone________________

Pharmacy Used?             Y/N____         Name___________________________    Phone________________

Mental Hlth Provider?      Y/N____         Name___________________________    Phone________________

Other Svc Provider?        Y/N____         Name___________________________    Phone________________

Miscellaneous Other   _____________________________________________________________________

Information

                                    _____________________________________________________________________

                                          

Do you wish to receive emergency preparedness information?  ___ Yes ___ No

I authorize this information to be used by Emergency Planners and Emergency Service workers in Jackson/and or Josephine Counties to assist me in the event of an emergency and in preparation for such event. 

 

I understand that I will be contacted every quarter to make sure my information is current, and that failure to provide updated information may result in my record being dropped from the Disaster Registry.

 

Applicants Name (Print)______________________   Signature _______________________   Date__________

Preparer’s Name (Print)______________________   Signature _______________________   Date__________

 

                                                                                                      




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