Functional Needs Registry — Marion County, Illinois

Voluntary signup for Marion County residents who would benefit from personal outreach during a disaster — an in-person door-knock, a phone call, or a welfare check by a deputy or EMA staff member during evacuations, prolonged power outages, severe-weather shelter activations, or other emergencies. There is no fee. You may remove your name at any time.

I. About You

The household this registration covers, and the best way for a deputy or EMA staff member to reach you.

Full name *

Address * The street address where you want emergency-response staff to come during a disaster.

City

ZIP code

Phone number * Best number to reach you at during an emergency.

Email Optional. Used only to send your confirmation and an update / unsubscribe link.

II. Functional Needs

Check every category that applies. This helps responders know what kind of assistance you may need — large-print materials, sign language, mobility access, oxygen, dialysis schedule, and so on.

Vision impairment (blind, low-vision) Hearing impairment (deaf, hard-of-hearing) Mobility impairment / wheelchair / walker Oxygen-dependent Dialysis-dependent Cognitive disability / dementia / autism Limited English (preferred language in comments) Other medical equipment dependence Other (describe below)

Additional detail Specific equipment, preferred language, assistance animal, or any other operationally useful info.

III. Caregiver & Emergency Contact

Optional. If you have a regular caregiver, or a family member who should be notified if a deputy needs to reach you and can’t, please share their information here.

Caregiver name

Caregiver phone

Emergency contact name

Emergency contact phone

IV. Anything Else?

Optional. Anything else MCEMA should know — gate combinations, preferred entrance, dog on premises, hours when no one is at home, and so on.

Comments

Your information is held by Marion County only. No record is created until you submit.

Functional NeedsRegistry.

Functional Needs
Registry.