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Do not include any sensitive information on this form or (if applicable) files uploaded to this form. Sensitive information includes, but is not limited to, social security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.
This form mirrors the functional needs card that is published in the yearly mailer to the community. Those who may need special accommodations during a major disaster or during an evacuation should fill out this card. Family members and close friends of those needing assistance are encouraged to help their loved one fill out this electronic form, the handwritten card, or sign up for B-WARN!. All of these methods cause us to enter the person's contact information into our contact list in B-WARN! that we use during a disaster. Only one method needs to be filled out to get on our list. This list is only good for one year. You must update the list yearly.
By submitting this form, you are agreeing to share your data to emergency management for the purpose of helping you during a disaster. Emergency Management will hold the information confidential and only share your information with agencies who work in the emergency operations center.
Are you filling this form out for:
Type Name of Organization you represent if your Organization offers service to help others fill out this form.
For the person potentially needing aid, please mark ALL of the conditions that apply to the person. Please understand that be choosing to share your conditions, we will be able to better understand how to help in an emergency.
Mark ALL that apply that would be an issue during an emergency:
Mark ALL that likely would apply during an ordered evacuation:
Describe pets/animals this person has that would need to be cared for, evacuated with the person, or otherwise might be a concern if a disaster occurred.
In Berrien County, we use IPAWS and B-WARN! to alert people of an emergency. IPAWS, when turned on, will automatically alert a cell phone without needing to sign up. B-WARN!, when signed up will call a landline phone, cell phone, email, fax, and/or pager. We also call the National Weather Service to set off NOAA Weather radios. The EAS system also broadcasts over TV and AM/FM radio tuned to local stations. Mark ALL below that apply to the person.
Does this person reside in Berrien County:
Check ALL months they are in Berrien County:
Does this person have anyone nearby who can help them in an emergency?
Do you want to add another helper?
Thank you for your time. Remember to update this form yearly.
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