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Emergency Response Information for Individuals with a Disabilities

  1. Name and Information for Person with Disibility

  2. Guardianship*

  3. Guardian Relationship

  4. Physical Description of Person with Disability

  5. Medical Information for Person with Disability

  6. Diagnosed Conditions*

  7. House Information

  8. Ex: where is your bedroom, do you use oxygen, have pets, etc

  9. Do you have a secondary, outside key for emergency purposes?

  10. Physical Disability*

  11. Invisible Disability*

  12. Verbal Communication

  13. Non-Verbal Communication

  14. Unique or Special Behaviors

  15. Explain, ex: yelling, giggles, stands to close)

  16. Explain, ex: Communication problems, combative, etc

  17. Sensory Overload (select what may result from sensory overload)

  18. What might Trigger Sensory Overload

  19. What calming mechanisms may work for any of the above behaviors

  20. For persons that are a flight risk, is there a favorite location they might be found or do they have a fixation on a particular person, place, or topic

  21. All information given on this form is confidential and secure. It will not be shared with any other organizations. Your information is only accessible to Jackson County Dispatch and Emergency Responders.

  22. In the event you need to make changes to this information please call Jackson Dispatch Offices at 517-768-7957.

  23. CodeRED

    Code Red is a program to notify Jackson county residents in the event of emergency situations or critical community alerts. Examples include: evacuation Notices, bio-terrorism alerts, boil water notices, and missing child reports. You can enroll for alerts here https://public.coderedweb.com/CNE/en-US/BF0404520300

  24. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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  26. This field is not part of the form submission.