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SHELTER REGISTRATION FORM <br />Anmic:AN RED CROSS <br />SHELTER REGISTRATION FORM <br />Please print aFl seCriWrs <br />Incident DR ivuunber & Name, <br />Shelter \ante <br />Shelter City. Coamty'Parish. State, <br />Family Name (Last Name): <br />Total fancily members registered. <br />Total family members sheltered: <br />Pre- Disaster Address (City Post- Disaster Address Ofdiffererlt) (City/State/Zip): <br />State /Zip): <br />Identification verified by (Record type of <br />ID: if tine.. write hone): <br />Ilolnle Phone: Cell Pholle"Otller: <br />primary Laugua 2e: If prmiary language is <br />not English, please list any farnily <br />members who speak English. <br />Method of Transportation: <br />If personal vehicle plate #;`State: <br />(f0]" Securi 1 jptlljilows 01111') <br />INFORMATION ABOUT ]INDIVIDUAL FAMILY MENIBERS (for add tional names. rise back of page) <br />Name (Last . First) <br />Age <br />Gender <br />(N1,'F) <br />Rni.lCot <br /># <br />Arrival <br />Date <br />Departure <br />Date <br />Departing? Relocation address and <br />phone <br />Are you required by lass- to register xeith any state or local goveramlent agency for any reason? <br />D Yes D No If Yes. please ask to speak to the shelter Manager immediately, <br />I acknowledge that I have rea&been read and understand the Red Cross shelter piles and agree to abide by therm. <br />Signature <br />CONTFIDEN°rLA,LITY STATEMENT <br />American Red Cross generally u ill not share personal information that you have provided to them with others without your <br />agreement. In some circumstances disclosure could be required by law or the Red Cross could determine that disclosure would <br />protect the health or well - being of its clients, others, or the community, regardless of you preference. <br />Below. please initial if you agree to release information to other disaster relief, voluntary or non -profit organizations and/or <br />govenuitental agencies providing disaster relief. <br />I agree to release my information to other disaster relief voluntary or non -profit organizations <br />I agree to release my information to goverrtnental agencies providing disaster relief <br />By signing here, I acknowledge that I have read the confidentiality statement and understand it <br />Signature <br />Date: <br />Shelter Worker Signature <br />After registration, each family should go through the Shelter Initial Intake Fonn to detennine if further assistance or accommodation <br />is needed. <br />For Red Cross Use Only F.— 5472 Re, 02 1 07 <br />Copy Distribution <br />1_ Shelter registration on -site file -Mass Care 2. Information Management (Data Entry) 3. Client (ifregnested) <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />Attachment number 12 <br />F -6 Page 285 <br />