Application for Town of Stratford Registry for Residents with Medical and Special Needs

Conditions and Authorization to Release Information, Including Protected Health Information

PLEASE READ THE FOLLOWING BEFORE COMPLETING THE ONLINE APPLICATION BELOW:

I understand that my participation in the Town of Stratford STRATFORD ALERTS is voluntary and that all information provided will only be used for emergency planning and response purposes.

I understand that, at any time, I can request that my name and information be removed from the STRATFORD ALERTS! by submitting a request in writing to the Stratford Health Department.

I understand information will only be used to assist first responders in understanding the condition with which they will be met upon responding, but does not guarantee a specific level of care/service be provided.

I understand that my enrollment in the STRATFORD ALERTS! does not guarantee that transportation or support services will be provided by the Town of Stratford during an emergency or disaster.

I understand that I remain responsible for myself in the event of an emergency and should call 911 if I find myself in a life-threatening situation.

I understand that I remain responsible for any costs associated with hospital or other medical care.

I understand that I am responsible for making my own emergency preparations, including the provision of medications, medical equipment and supplies, and dietary items that may be required if I am evacuated from my home.

I understand that assistance may only be provided for pre-event communication/planning and during the duration of an evacuation, emergency, or disaster event.

I grant permission for the release of this information to State and local emergency medical providers, transportation agencies, and other emergency preparedness and response partners working with the Town of Stratford during times of disaster or emergency.

I hereby confirm and attest that the information voluntarily provided in this registration is true and correct to the best of my knowledge. Should the information that I have provided need to change or should I wish to be removed, I will provide a request in writing. I have had the full opportunity to read and consider the contents of this Authorization. I understand that, by completing the application and signing below, I am confirming my authorization that the Stratford Health Department may disclose the information described above to the organizations named within this form. I understand the limitations on service and the level of care available.

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