Consent

Terms and Conditions for Functional Needs Registry Participation
Please read the following information carefully. If you have any questions or need more information, please contact the City of St. Louis Department of Human Services at (314) 657-1676 or toll-free (877) 612-5918
Participation in the Functional Needs Registry (Registry) is voluntary. No one is required to participate. Individuals are included in the Registry ONLY with their permission.
Submitting an application to participate in the Functional Needs Registry does not guarantee that an individual will be included in the Registry. Even if an individual is included as a participant in the Registry, there is no guarantee that the individual will receive immediate or preferential treatment in an emergency or disaster situation.
Individually identifiable participant information in the Functional Needs Registry is confidential and will not be shared with the general public. This information will be released to public health authorities, human services agencies, and other emergency response agencies on a need-to-know basis to provide the necessary services in the event of an emergency or disaster. Aggregated non-identifiable participant information will be used and disclosed to plan for the provision of emergency and disaster services.
Participants can withdraw their permission to be included in the Functional Needs Registry at any time by providing written notification of withdrawal to the City of St. Louis Department of Human Services, 1520 Market Street, 4th Floor, St. Louis, MO 63103, ATTN: (Functional Needs Registry).
Participants in the Functional Needs Registry may be responsible for all expenses associated with medical evacuation and shelter at a hospital or nursing facility or for any specialized equipment needed in a functional needs shelter.
By submitting this application, I hereby agree to the following terms and condition for participation in the Functional Needs Registry:
  • The information that I have provided in this application is correct.
  • I give my permission to participate in the Functional Needs Registry and to include my information in the Registry.
  • I consent to the release of my information on the Functional Needs Registry to public health authorities, human services agencies, and emergency response agencies as necessary to provide services to me in an emergency or disaster situation.
  • I give local law enforcement and/or medical personnel my permission to enter my home to provide emergency services in an emergency or disaster situation.
  • I understand that being a participant in the Functional Needs Registry does not guarantee that I will receive emergency response services in an emergency or disaster situation.
  • I understand that I can withdraw my permission to participate in the Functional Needs Registry by notifying the City of St. Louis, Department of Human Services, 1520 Market Street, 4th Floor, St. Louis, MO 63103, ATTN: (Functional Needs Registry) and that upon receipt of such notification, the Department of Human Services will remove my information from the Registry.
  • I understand that as a participant in the Functional Needs Registry, I may be responsible for all expenses associated with medical evacuation and shelter at a hospital or nursing facility or for any specialized equipment needed in a functional needs shelter.
Rev 9/01/08