Elder and Disabled Adult Disaster Registry

Title 34 Virgin Islands Code, chapter 16 subchapter II established the Elder, Dependent Adult, and Disabled Persons Disaster Registry. Title 34 Virgin Islands Code, chapter 16, subchapter II, section 521 states, “The Department of Human Services shall issue forms to the Bureau of Motor Vehicles and the Virgin Islands Elections System to be used to collect the information for the registry.

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Name

First

Last

Primary Telephone

Secondary Telephone

Physical Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Directions to the Address:

(Include landmarks, color or home and all other recognizable features)

Emergency Contact Information

Name

First

Last

Primary Telephone

Secondary Telephone

Additional Information

Are you Mobile?

Are you on Medication?

Do you live alone?

Signature of Registrant: