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ND Special Needs Registry
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Special Needs Registration - All fields with an * are required.


please use any alpha or numeric characters to create your access code
(xxxxx)


Please set the map marker location for the special needs registrant.

Use the "Set Map Marker Via Address" button to have the marker move to the above address; please then verify the marker location. If needed click and drag the marker to the registrants correct location.



()  - 
()  - 
 (mm/dd/yyyy)

 Lives Alone  Lives with Others
 yes  no

Additional contact information (Primary)
- This person will be contacted if we are unable to reach you during an emergency.
()  - 
()  - 

Additional Contact Information (Secondary)
- This person will be contacted if we are unable to reach you or your primary contact during an emergency.
()  - 
()  - 

Out of Area Contact - an out of area contact is someone we are able to call in case of an emergency who is not likely to be affected by an emergency impacting the registrant.
()  - 
()  - 

Submitter Information (if different than registrant)
()  - 
 yes  no  unknown

Additional Information
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no
 yes  no

Primary Physician Information
()  - 

Other
Additional Information About Your Needs That Would Assist Emergency Planners and Responders:


In the event of an actual emergency, evacuation, or any type of disaster, response agencies will attempt to provide the necessary assistance, but the N.D. Department of Emergency Services (NDDES) and other response agencies cannot gaurantee you will receive help. NDDES strongly recommends and urges you to take all necessary precautions to protect your person(s) and property prior to and during an emergency, evacuation, or disaster.


In the event of an actual emergency, evacuation, or any type of disaster, response agencies will attempt to provide the necessary assistance, but the N.D. Department of Emergency Services (NDDES) and other response agencies cannot gaurantee you will receive help. NDDES strongly recommends and urges you to take all necessary precautions to protect your person(s) and property prior to and during an emergency, evacuation, or disaster.


I authorize emergency response personnel to enter my home during search and rescue operations following a disaster, if necessary to assure my safety and welfare.

I understand that information I provide is strictly confidential and will be used only for emergency planning and response purposes. I agree information may be disclosed and used to assist emergency services personnel, medical providers, transposrtation agencies, and others as necessary to provide care and respond to my needs durings an emergency, evacuation, or disaster.

* Signature: 
(type your name in lieu of written signature)

* Who's Signature:  Registrant's  Guardian or Legal Representative

This site updated as of 11/20/2017.