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People with special needs who live in Alabama's Chemical Stockpile Emergency Preparedness Program zones in Calhoun, Clay, Cleburne, Etowah, St. Clair and Talladega counties can register with their state and county Emergency Management Agency. Please register each household member with special needs who requires assistance. For more information, click Registration or call 256-236-8642 or 800-263-0201.
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| First Name: |
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| Middle Name: |
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| Last Name: |
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| Suffix: |
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| Age: |
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| Street Address: |
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| City: |
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| State: |
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| Zip Code: |
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| County: |
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Mailing Address:
(If Different
From Above Address) |
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| Phone Number: |
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| Alternate Phone Number: |
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| TTY / TDD Phone Number: |
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| Email Address: |
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| Name Of Alternate Contact: |
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| Phone Number: |
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| Caregiver's Name: |
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| Phone Number: |
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During an emergency, your county Emergency Management Agency may advise you to shelter in place or evacuate. Please tell us if you are unable to take a protective action without help and you do not have a help network of nearby family, neighbors or friends.
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| Can you evacuate either alone or with your help network? |
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| Can you shelter in place either alone or with your help network? |
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Children who are home alone for any length of time and do not have nearby family, neighbors or friends can be registered. If your child qualifies, list their name and age below.
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| Children Who May Be Home Alone |
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Please mark all conditions that apply to you.
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| Severe Vision Problem: |
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| Reading Requirements: |
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| Severe Hearing Problem: |
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| Severe Mobility Problem: |
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| Mobility Aids: |
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| Cognitive, Mental or Emotional Conditions: |
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| Medical Equipment Used: |
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| Breathing Difficulty: |
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| Other Information: |
Heart Condition
Nonverbal
Diabetic
Dialysis
Medical Equipment Requires Electricity
Home Has Backup Power Supply
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| I live in a: |
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| I do not understand English: |
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| My native language is: |
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| People who could not evacuate because they do not have transportation can register. |
| I can't evacuate because: |
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| Please Provide Other Important Information |
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| Submitted by (if other than the registrant): |
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| Relationship: |
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| Telephone Number: |
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By submitting this information, you can help your state and county emergency management agencies better plan to assist you during an emergency. Creating a personal emergency preparedness plan and a help network are vital when planning for any emergency. During a disaster, federal, state and county agencies may not be able to respond due to an overwhelming number of requests for assistance. This information is being gathered under the authority of the State of Alabama for the purpose of protecting the public. The State will protect your privacy and all confidential information that you provide. If you do not want to submit your personal information online, call 256-236-8642 or 800-263-0201.
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