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1 T h e G l o u c e s t e r T o w n s h i p P o l i c e E m e r g e n c y N e e d s P r e p a r e d n e s s R e g i s t r y I N S T R U C T I O N S A N D I N F O R M A T I O N T h e G l o u c e s t e r T o w n s h i p P o l i c e D e p a r t m e n t ( G T P D ) h a v e c r e a t e d a v o l u n t a r y E m e r g e n c y N e e d s P r e p a r e d n e s s R e g i s t r y t o i d e n t i f y r e s i d e n t s w h o m i g h t n e e d e x t r a a s s i s t a n c e d u r i n g a m a j o r e m e r g e n c y, s u c h a s a m a s s e v a c u a t i o n, a p u b l i c h e a l t h e m e r g e n c y l i k e a p a n d e m i c, o r a n i n d e p e n d e n t e m e r g e n c y l i k e a h e a l t h c r i s i s o r f i r e i n y o u r h o m e. T h e t o w n s h i p s e m e r g e n c y r e s p o n s e w i l l b e m o r e e f f e c t i v e i f r e s p o n d e r s a r e a w a r e o f y o u r s p e c i a l s i t u a t i o n p r i o r t o t h e i r a r r i v a l. Y o u n e e d s p e c i a l n o t i f i c a t i o n a b o u t t h e e m e r g e n c y d u e t o i m p a i r m e n t o r l a n g u a g e b a r r i e r. Y o u n e e d a s s i s t a n c e t o l e a v e y o u r h o m e d u e t o a d i s a b i l i t y o r o t h e r p h y s i c a l c h a l l e n g e s. Y o u h a v e n o a c c e s s t o t r a n s p o r t a t i o n. Y o u c o u l d n o t s t a y i n y o u r h o m e w i t h o u t a s s i s t a n c e f o r m o r e t h a n a c o u p l e o f d a y s. Y o u r e l y u p o n e l e c t r i c a l p o w e r f o r s p e c i a l i z e d e q u i p m e n t i n y o u r h o m e. T h e R e g i s t r y : P r o v i d e s e m e r g e n c y p l a n n e r s w i t h y o u r i n f o r m a t i o n s o t h a t d u r i n g a d i s a s t e r, r e s p o n d e r s c a n d e t e r m i n e w h e r e s p e c i a l a s s i s t a n c e i s r e q u i r e d. K e e p s y o u r i n f o r m a t i o n s e c u r e. I t w i l l o n l y b e u s e d f o r e m e r g e n c y p r e p a r e d n e s s o r r e s p o n s e. W h i l e e n r o l l m e n t i s n o g u a r a n t e e t h a t y o u w i l l g e t h e l p f i r s t d u r i n g a d i s a s t e r, t h e G T P D E m e r g e n c y O p e r a t i o n s C e n t e r w i l l k n o w o f y o u r n e e d f o r s p e c i a l a s s i s t a n c e. P l e a s e r e m e m b e r, e v e n i f y o u a r e o n t h e E m e r g e n c y N e e d s P r e p a r e d n e s s R e g i s t r y, y o u s h o u l d c a l l i f y o u f i n d y o u r s e l f i n a l i f e - t h r e a t e n i n g s i t u a t i o n. P a g e 1 o f 5
2 Y o u m a y e n r o l l y o u r s e l f o r a n y o n e e l s e f o r w h o m y o u h a v e l e g a l r e s p o n s i b i l i t y. S i m p l y c o m p l e t e a n d s i g n t h e a t t a c h e d f o r m. P l e a s e r e p o r t a n y c h a n g e s i n y o u r i n f o r m a t i o n i m m e d i a t e l y t o t h e G T P D b y c o m p l e t i n g a n u p d a t e d a p p l i c a t i o n f o r m. W e w i l l c o n t a c t y o u a n n u a l ly t o r e m i n d y o u t o u p d a t e y o u r i n f o r m a t i o n. I t i s r e c o m m e n d e d t o h a v e a r e c e n t p h o t o o n f i l e. P l e a s e c o n t a c t t h e G T P D C o m m u n i t y R e l a t i o n s B u r e a u w h e r e y o u c a n r e q u e s t a s s i s t a n c e t o h a v e a p h o t o t a k e n t o b e k e p t o n f i l e. T h e E m e r g e n c y P r e p a r e d n e s s N e e d s R e g i s t r y f o r m c a n b e p r i n t e d o u t o n t h e G T P D w e b s i t e a t h t t p : / / w w w. g t p o l i c e. c o m / p r o g r a m s / e m e r g e n c y - n e e d s - p r e p a r e d n e s s / o r p i c k e d u p a t p o l i c e h e a d q u a r t e r s. T h e c o m p l e t e d f o r m s c a n a l s o b e m a i l e d t o : G l o u c e s t e r T o w n s h i p P o l i c e A t t n : C o m m u n i t y R e l a t i o n s B u r e a u C h e w s L a n d i n g R o a d L a u r e l S p r i n g s, N J I f y o u h a v e q u e s t i o n s o r n e e d f u r t h e r i n f o r m a t i o n, p l e a s e c a l l t h e G T P D C o m m u n i t y R e l a t i o n s B u r e a u a t o r e m a i l t h e m a t c o m m u n i t y r e l a t i o n G T P o l i c e. c o m. POLICE ONLY SECTION: DATE RECEIVED: OFFICER: SUPERVISOR APPROVED: DATE ENTERED: OFFICER: SUPERVISOR APPROVED: P a g e 2 o f 5
3 E m e r g e nc y P r e p a r e d n e s s R e g i s t r a t i o n F o r m I f y o u, o r a n y m e m b e r o f y o u r h o u s e h o l d, r e q u i r e e x t r a a s s i s t a n c e i n t h e e v e n t o f a m a j o r e m e r g e n c y s u c h a s a n e v a c u a t i o n, p l e a s e c o m p l e t e a n d r e t u r n t h i s f o r m s o t h a t y o u r s p e c i a l n e e d s w i l l b e a v a i l a b l e t o e m e r g e n c y r e s p o n s e p e r s o n n e l. T h e T o w n s h i p o f G l o u c e s t e r w i l l o n l y u s e y o u r i n f o r m a t i o n f o r e m e r g e n c y p r e p a r e d n e s s a n d r e s p o n s e. S P E C I A L A S S I S T A N C E W O U L D B E N E E D E D F O R : F I R S T N A M E L A S T N A M E D A T E O F B I R T H H O M E A D D R E S S W I T H Z I P C O D E H O M E P H O N E C E L L P H O N E T T Y / T T D # E M A I L A D D R E S S P R I M A R Y L A N G U A G E C h e c k o n l y t h o s e a p p l i c a b l e : N O N - E N G L I S H S P E A K I N G H O M E P a g e 3 o f 5
4 T R A N S P O R T A T I O N D U R I N G A N E V A C U A T I O N - s t o p S p e c i f y ) D I S A B I L I T Y o r o t h e r C H A L L E N G E S i m p a i r e d D E P E N D E N C Y S p e c i f y ) _ - I r e q u i r e e l e c t r i c i t y f o r e s s e n t i a l e q u i p m e n t. S p e c i f y ) O T H E R, S P E C I A L C I R C U M S T A N C E S a v e o n e o r m o r e c h i l d r e n u n d e r a g e 1 8 l i v i n g w i t h m e. I M P O R T A N T I N F O R M A T I O N : E M E R G E N C Y C O N T A C T ( N o t i n h o u s e h o l d ) R E L A T I O N S H I P A D D R E S S P a g e 4 o f 5
5 E M E R G E N C Y C O N T A C T # 2 R E L A T I O N S H I P A D D R E S S P R I M A R Y P H Y S I C I A N N A M E ( O p t i o n a l ) A U T H O R I Z A T I O N I r e q u e s t r e g i s t r a t i o n i n t h e G T P D E m e r g e n c y N e e d s P r e p a r e d n e s s R e g i s t r y. I c e r t i f y t h a t I h a v e v o l u n t a r i l y p r o v i d e d t h e a b o v e i n f o r m a t i o n a n d t h a t i t i s t r u e a n d c o r r e c t t o t h e b e s t o f m y k n o w l e d g e. I h a v e r e a d t h e i n f o r m a t i o n s h e e t a t t a c h e d w i t h t h i s r e g i s t r y f o r m a n d I u n d e r s t a n d t h e l i m i t a t i o n s o n s e r v i c e s a n d t h e l e v e l o f c a r e a v a i l a b l e. I u n d e r s t a n d t h a t I r e m a i n r e s p o n s i b l e f o r a n y c o s t s a s s o c i a t e d w i t h h o s p i t a l o r o t h e r m e d i c a l c a r e. I u n d e r s t a n d t h a t e n r o l l m e n t i n t h e r e g i s t r y i s n o g u a r a n t e e t h a t t r a n s p o r t a t i o n o r s u p p o r t s e r v i c e s w i l l b e p r o v i d e d b y t h e T o w n s h i p o f G l o u c e s t e r. I u n d e r s t a n d t h a t I r e m a i n r e s p o n s i b l e f o r m y s e l f i n t h e e v e n t o f a n e m e r g e n c y a n d I s h o u l d c a l l i f I f i n d m y s e l f i n a l i f e - t h r e a t e n i n g s i t u a t i o n e v e n i f I a m o n t h e r e g i s t r y. I g r a n t p e r m i s s i o n t o e m e r g e n c y r e s p o n d e r s, m e d i c a l p r o v i d e r s, t r a n s p o r t a t i o n a g e n c i e s a n d o t h e r s i n v o l v e d i n m y c a r e t o e n t e r m y h o m e, p r o v i d e c a r e a n d d i s c l o s e a n y i n f o r m a t i o n n e c e s s a r y t o r e s p o n d t o m y h e a l t h n e e d s d u r i n g a n e m e r g e n c y. I g r a n t p e r m i s s i o n f o r t h e r e l e a s e o f t h i s i n f o r m a t i o n t o e m e r g e n c y a g e n c i e s a n d p e r s o n n e l. P R I N T N A M E / R E L A T I ON: _ A D D R E S S : _ P H O N E : _ E M A I L : _ D A T E : S I G N A T U R E : _ P a g e 5 o f 5
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