Statement of Purpose

The Access and Functional Needs Registry is a secure database of information administered by the Department of Human Services (DHS). The Registry is intended to serve as an emergency preparedness tool whereby the elderly, disabled, and those with temporary mobility needs can provide Saint Louis County emergency response agencies with information about any medical or physical conditions that could interfere with their ability to respond to disasters or other emergencies in a safe and timely manner. In turn, emergency response agencies can use this information to better plan and more effectively provide emergency response for individuals that may need additional assistance during these events.

Participation Guidelines

• PARTICIPATION IN THE REGISTRY IS STRICTLY VOLUNTARY. YOU MAY CHOOSE TO ADD YOURSELF TO OR TERMINATE YOUR PARTICIPATION IN THE REGISTRY AT ANY TIME. SHOULD YOU CHOOSE TO TERMINATE YOUR PARTICIPATION IN THE REGISTRY, YOU MAY DO SO BY SUBMITTING A REQUEST IN WRITING.
• FAMILY MEMBERS, CAREGIVERS OR FRIENDS MAY ENROLL QUALIFIED REGISTRANTS WITH THEIR PERMISSION, UNLESS REGISTRANT HAS A DURABLE POWER OF ATTORNEY. IN SUCH CASE, THE DESIGNATED DECISION-MAKING AGENT MUST COMPLETE APPLICATION FOR REGISTRANT.
• BEFORE BEING FORMALLY ADDED TO THE REGISTRY, THE COMPLETENESS OF YOUR APPLICATION WILL BE REVIEWED.
• IT IS CRITICAL THAT YOU UPDATE YOUR REGISTRY PROFILE INFORMATION, AS NEEDED. A DISASTER OR OTHER EMERGENCY CAN OCCUR AT ANY TIME. IN ORDER FOR EMERGENCY RESPONSE AGENCIES TO ADEQUATELY PLAN TO ASSIST YOU IN AN EMERGENCY, IT IS IMPERATIVE THAT YOUR PROFILE INFORMATION IS CURRENT. IF THERE ARE ANY CHANGES TO YOUR ADDRESS, PHONE NUMBER, MEDICAL CONDITIONS OR EMERGENCY CONTACTS, PLEASE UPDATE YOUR INFORMATION ON LINE, OR CONTACT THE REGISTRY COORDINATOR AS SOON AS POSSIBLE AT 314 615-4426.

Privacy of Information

It is the policy of DHS that all Registry participant information remains strictly confidential and that it is used solely for its intended purpose.

DHS has strict oversight of the Registry’s use and the distribution of its information. Aggregate Registry information such as non-individually identifiable participant information by geographical area, will be available to Saint Louis County emergency response agencies for the purposes of planning for disasters or other emergencies.

Individually identifiable participant information such as name, address, phone number and medical information will be available to Saint Louis County emergency response agencies for the purposes of coordinating emergency response. Emergency response agencies will make every attempt to locate and assist potentially-affected residents, including Registry participants, in actual emergencies.

DHS may, from time to time, use the services of volunteers for clerical support. Any person providing volunteer services in connection with the Registry will have restricted access to protected information and will be required to sign a Confidentiality Agreement as a condition of their service.

Personal Preparedness

Your participation in the Registry does not guarantee that you will receive priority assistance or preferential treatment in the event of a disaster or other emergency. Registry participants are strongly encouraged to make individualized emergency preparedness plans. Learn about how to prepare one and find more emergency preparedness resources by visiting our website at www.stlouisco.com/LawandPublicSafety/EmergencyManagement/GetPrepared

Acknowledgements

• BY COMPLETING THIS REGISTRATION, I AGREE THAT MY NAME AND OTHER INFORMATION AS HERE REPORTED WILL BE ADDED TO THE SAINT LOUIS COUNTY’S ACCESS AND FUNCTIONAL NEEDS REGISTRY. I CERTIFY THAT THE INFORMATION I’VE PROVIDED IN THIS APPLICATION IS TRUE AND TO THE BEST OF MY KNOWLEDGE.
• I HAVE READ AND UNDERSTAND THE TERMS OF THIS PARTICIPATION AGREEMENT. I AGREE TO ADHERE TO THE REQUIREMENTS OUTLINED HEREIN. I UNDERSTAND THAT ENROLLING IN THE REGISTRY DOES NOT GUARANTEE THAT I WILL RECEIVE ASSISTANCE IN THE EVENT OF AN EMERGENCY. I HAVE BEEN ADVISED ABOUT THE IMPORTANCE OF HAVING AN INDIVIDUALIZED EMERGENCY PREPAREDNESS PLAN AND HAVE RECEIVED INFORMATION ABOUT RESOURCES AVAILABLE TO ASSIST ME IN PREPARING ONE.
• I HEREBY GRANT SAINT LOUIS COUNTY’S DEPARTMENT OF HUMAN SERVICES ACCESS AND FUNCTIONAL NEEDS REGISTRY PERMISSION TO USE AND SHARE THIS INFORMATION WITH SAINT LOUIS COUNTY EMERGENCY RESPONSE AGENCIES INCLUDING BUT NOT LIMITED TO THE OFFICE OF EMERGENCY MANAGEMENT, FIRE DEPARTMENTS, LAW ENFORCEMENT, EMERGENCY MEDICAL SERVICE PROVIDERS AND LOCAL HEALTH CARE AGENCIES FOR THE PURPOSES OF EMERGENCY PLANNING AND RESPONSE. I ALSO HEREBY GRANT EMERGENCY RESPONDERS PERMISSION TO ENTER MY RESIDENCE DURING AN EMERGENCY IF DEEMED NECESSARY TO ENSURE MY SAFETY AND WELFARE. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY CHARGES ASSOCIATED WITH MEDICAL TREATMENT OR TRANSPORTATION, SHOULD I REQUIRE THESE SERVICES IN THE EVENT OF AN EMERGENCY.
• I RELEASE SAINT LOUIS COUNTY, ITS OFFICERS, AGENTS, EMPLOYEES AND VOLUNTEERS INCLUDING THOSE OF THE OFFICE OF COMMUNITY SERVICES, FROM ANY ACT OF NEGLIGENCE OR FAULT WHICH ARISES IN THE FUTURE DURING THE COURSE OF THE SERVICES PROVIDED TO ME IN CONNECTION WITH THE AFNR.