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Medically Fragile Individuals
Page 1 of 4
VOLUNTARY REGISTRATION REQUEST FOR MEDICALLY FRAGILE INDIVIDUALS

DATE: September 1, 2008

Dear Citizen:

Sierra County Health and Human Services keeps a Medically Fragile Registry (MFR) of people with special needs. In case of fire, flood, earthquake or other disaster Human Services will try to provide medical shelter and transportation. Please fill out the attached form if you have a lasting medical condition. The information will help us help you in an emergency. Registering is completely voluntary. Once you have filled out the form, return it to:

Sierra County Health Department
202 Front Street
P. O. Box 7
Loyalton, CA 96118

If you have any questions, call the Emergency Preparedness Coordinator at (530) 993-6737.

Registration Form: The information that you give on this form will stay confidential. It will only be given to first response agencies that will help you with your emergency evacuation or medical need. It is recommended that you put a list of the doctors treating you, pharmacies, medications you are taking (including doses), and any special dietary information on your refrigerator. Giving us the most complete information possible will speed help in an emergency.

Evacuation: You must be ready to leave your home when told to do so by emergency officials. In a disaster, the high demand for emergency services may slow or prevent them from reaching you. Be sure to make a personal evacuation plan and share it with your family, friends, neighbors, or community organizations that can help you in an emergency. Here are some ways you can help yourself prepare.
  • Ask family members to help you with transportation.
  • Talk to your doctor about emergency transportation and sheltering. If you need medical shelter, have him or her complete the needed pre-admission paperwork now.
  • Talk to your friends and neighbors about how you can help each other in an emergency. Some things that you can do include carpooling and setting up a buddy system to look after each other.
  • If you live in an apartment complex or trailer park, ask the manager if there is a disaster plan.
Pet Care: Most shelters do not allow you to bring pets. Make arrangements for your pets now in case of emergency. Ask the County Agriculture Commissioner about pet sheltering. Keep these items available: current rabies and vaccination records, a pet carrier, and enough pet food and water for an emergency.

Important: You are responsible for paying all shelter, ambulance or other medical transportation costs. Sierra County will not pay for these services.



* Name:
Spouse:
* Physical Address:
Apt/Lot:
City:
Mailing Address (if different from above):
Phone:
Do you live in a mobile home?
If yes, what is the complex name?
Are you a seasonal resident?

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