Disclaimer* I understand that completing this form and including my information in the Iredell
County Special Medical Needs Registry and the State Special Needs Registry DOES NOT
create a contract for services. Neither the entities or individuals that have created or
maintained this registry or collected information for this registry, nor any entity or individual that may utilize the information contained in the registry including but not limited to, Iredell
County Emergency Management, the Department of Public Safety, Division of Emergency Management, Public Health authorities, human services agencies, emergency personnel and volunteers, warrant that assistance will be provided to you during an emergency or disaster.
I understand that participation in this registry is voluntary and this it is my duty and responsibility to update my information on this registry. By completing this registration form and including the information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry, I hereby confirm and attest that the information provided in
this registration is correct and that should the information that I have provided change, I will promptly update the registry.
By completing this registration form and including the information in the Iredell County Special Medical Needs Registry and the State Special Needs Registry, I also hereby warrant that the information has been provided voluntarily and that if I have required assistance to complete this form that I have consented to the assistance provided. By completing this registration form and including the information in
the Iredell County Special Needs Registry and State Special Needs Registry, I also hereby waive any and all claims which relate to the collection, maintenance or use of the information I have supplied which may be asserted against the entities or individuals that have created or maintained this registry or collected information for this registry and any entity or individual that may utilize the information contained in the
registry including but not limited to the Department of Public Safety, Division of Emergency Management and emergency personnel and volunteers.
I understand that my participation in the Iredell County Special Medical Needs
Registry and State Special Needs Registry is voluntary and that all information I provide, including any Protected Health Information, will be treated as confidential, but that under some limited circumstances the information may be released without my permission as allowable by federal or state law.
I further understand that the information I provide will only be released to the
Department of Public Safety, Division of Emergency Management, the County of Iredell and Public Health authorities, human services agencies, emergency responders, managers and planners, and those individuals who manage the Registry database.
I understand that the information I have provided to the Registries will only be
used in the following circumstances: to respond to disaster-related events; to respond to emergency needs; for evacuation and recovery efforts; and for disaster planning purposes.
I understand that under some limited circumstances the information may be
released without my permission as allowable by federal or state law.
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION
I understand that I, or my personal representative, is entitled to receive a copy of the completed authorization form upon request. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke the authorization I must do so in writing and submit my written revocation to Iredell County Emergency Management. I understand that the revocation will not apply to information that has already been released. I also understand that once information is released to others, it may be re-disclosed to
individuals or organizations not subject to state and federal privacy and confidentiality laws and may not be protected.
I have had full opportunity to read and consider the contents of this Authorization. I
understand that, by signing this form, I am confirming my authorization that the Department of Public Safety, Division of Emergency Management may disclose to the person(s)/organization(s) named in this form the information described in this form.
I certify that the above information is correct. I hereby authorize the Department of Public Safety, Division of Emergency Management, to release, use or disclose this information to other emergency response or human service agencies or officials and to include this information in the State Special Needs Registry. I also give law enforcement permission to enter my home in case of an emergency. I understand that I have the right to revoke this permission by notifying Department of Public Safety, Division of Emergency Management and asking that my name be removed from the special needs registry.