Colington United Methodist Church
Special Needs Registration
Name:___________________________________________ Date:________________________
Address: ______________________________________________________________________
Directions to your home: _________________________________________________________
______________________________________________________________________________
Telephone(s) (Home, Work, Cell): _________________________________________________
E-mail:________________________________________________________________________
Age: _________ Additional Info/Medical Needs: ______________________________________
______________________________________________________________________________
______________________________________________________________________________
Caregiver/Local Emergency Contact: ___________________________ Phone:______________
E-mail:_______________________________________________________________________
Neighbor/Other Person: __________________________________ Phone: _________________
E-mail:_______________________________________________________________________
Who will help you with emergency preparations? _____________________________________
IN THE EVENT OF A MANDATORY EVACUATION WE URGE YOU TO FOLLOW THE ORDERS OF YOUR COUNTY’S EMERGENCY MANAGEMENT GROUP. THERE ARE NO EMERGENCY SHELTERS WITHIN THE IMMEDIATE AREA. ONCE A MANDATORY EVACUATION HAS BEEN ORDERED, COLINGTON UMC WILL BE UNABLE TO CONTACT YOU UNTILTHE ORDER HAS BEEN LIFTED.
Do you normally evacuate if a mandatory evacuation is ordered? □ Yes □ No
If you answered NO, where will you stay?
□ Home (Will you be alone? □ Yes □ No )
□ Family □ Friends □ Neighbor Name :______________________________________
Phone: ______________________________________
Would you like information on home safety emergency planning? □ Yes □ No
Use a separate sheet of paper to add any additional information and to write your emergency planning questions and/or concerns.
COLINGTON UNITED METHODIST CHURCH
I am able to provide assistance to others during an emergency.
Contact Information:
Name: ___________________________
Address: _________________________
_________________________________
_________________________________
Phone: (h)________________________
(w) ________________________
(c) _________________________
E-mail: ___________________________
Check the area that most closely identifies
the area where you live:
□ Colington/ Colington Harbor
□ Corolla/Duck
□ Currituck Mainland
□ Dare Mainland
□ Hyde County
□ Kill Devil Hills
□ Manteo
□ Nags Head
□ Southern Shores
□ Wanchese
Please list any skills you would be willing to share: ____________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Equipment:
Please check the equipment you have to use or lend to other members:
□ Boat
□ Chain Saw
□ 4-wheel drive vehicle
□ Generator/Fuel Containers
□ Grills
□ Hand Tools, Wheelbarrow
□ Pickup/Straight Truck/Trailer
□ Winch/Tow Ropes/Logging Chain
□ Ladders
□ Pump (Gas powered)
□ Other: ___________________________
___________________________________
Services: Please check services that you are able to provide:
□ Emergency Childcare
□ Hot Meal or Covered Dish
□ Labor to prepare for a storm
□ Labor to clean up after a storm
□ Radio Operator
□ Transportation
□ Work phone bank to coordinate relief
efforts
□ Medical Skills: ____________________
□ Other: ___________________________
Langauges: I am bilingual in English and: ____________________________________
Shelter: Please check the type of short term (up to one week) shelter you can provide:
□ Family with children: _______________
□ Family without children: ____________
□ Individuals: _______________________
□ Pets (type, #): _____________________
