State of Emergency

Mailbox Policy

Emergency Information

Right To Know Form

Pension Act 44 Compliance



Completely fill out the form, sign the form and then return the form to:

                        Earl Township
                        Emergency Management
                        517 N. Railroad Ave
                        New Holland, Pa 17557

Date of Initial Completion: ___________________________

House:  0  Home    0    Rent      0      MH/R Group Home       0    CYA Foster Home

Do you SPEAK English?   0    Yes    0    No           Do you READ English?   0    Yes     0    No
If the answer is NO, what is your Native Language? _____________________________________________

Personal Information

Name: _____________________________________________  Phone: ________________________

Address: ___________________________________________  Cell Phone:  ____________________
              ______________________________ Zip Code____________   Email: _________________________

Date of Birth: ________________________       0   
Male        0      Female

Mobility:  Check if the answer is ‘yes”
  0   Confined to Bed
  0   Confined to Wheelchair
  0   Require Medical Support Equipment, Oxygen/Ventilator, or Other: _________________________
  0   Walk with Walker, Cane or Other: ___________________________________________________
  0   Hearing Impaired - Do you have a TTY or similar device   yes      no
  0   Sight Impaired
  0   Other Personal Situation;  ___________________________________________________________
  0   Without any Personal Means of Transportation
  0   Service Animal

I might not be able to evacuate without help due to a : Mental Disability, Mental Retardation, Autism, Alzheimer’s or due to not being able to verbally respond.   0  
  Yes      0    No

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This is where I would hide if I was fearful (Inside, Outside): __________________________________
I must take medicine daily which is prescribed by my doctor:    0   Yes      0   No

Primary Care Physician:                                              Telephone Number: __________________________

Name:  ______________________________                 Address: ___________________________________

EMERGENCY CONTACT                                                EMERGENCY CONTACT

Name: _________________________________       Name: _____________________________________

Phone: _________________________________      Phone:  ____________________________________

Cell:  __________________________________       Cell:  ______________________________________

Address:  _______________________________      Address:  ___________________________________
_______________________________________      ____________________________________________

E-mail:  ________________________________       E-mail: ______________________________________

Relationship: ____________________________      Relationship: _________________________________

Do you have pets in the household needing evacuation?      0    Yes        0     No


Privacy Information:  Privacy of Health Information/HIPAA Dsiclosures in Emergency Situations

  May an emergency official make disclosures to public officials who are responding to any man-made or natural emergency?

 Yes.  Various agencies and public officials will need protected health information to deal effectively with a man-made or natural emergency. To facilitate the communications that is essential to a quick and effective response to such events, HIPAA permits covered entities to disclose needed information to public officials in a variety of ways.  Covered entities may disclose protected health information, without the individual’s authorization, to a public health authority acting as authorized by law in response to a man-made or natural emergency, see 45 CFR 164.512(b), (see 45 CFR 164.512(j), (see 45 CFR 164.512(f); 45 CFR 164.512(k)(2); or judicial and administrative proceedings (see 45 CFR 164.512(e))
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My Signature Below Authorizes Earl Township to Share the Information Provided by Me in the Attached Emergency Information Form with:

                  Lancaster County Emergency Management

                  Earl Township Emergency Management

                  Fire Department

                  Police Department

                  Earl Township Municipal Officials

                  Emergency Responders

                  Emergency Officials

My Signature Below Also Represents my Agreement with the Following Statements:

Liability:  Neither the County of Lancaster, Pa. (or any of its elected officials, employees, agencies or departments), Earl Township, Lancaster County, Pa. (or any of its elected officials, employees, agencies or departments), nor any of the individuals or entities involved in the accumulation of data, entry of data or use of the data can be assured of the accuracy, completeness, or reliability of the information provided by me or assure the use of that information in an emergency situation.  Under no circumstances shall the County of Lancaster, Earl Township (or any of their elected officials, employees, agencies or departments), or any of the other entities mentioned above, be liable to me, for any claims arising from the use of said information, and I release and discharge the same from any and all claims, demands, suits, causes of action, damages, costs and other legal or equitable remedies arising from the use or possession of said information.

Information:   I agree that you may retain my information and use it for emergency planning and response, effective from the date of my signature and continuing until / if I submit a signed, dated notice to the Earl Township Municipal Office, to the attention of Emergency Management, requesting that they remove my information.  I understand that Earl Township may contact me to verify my information, and if I fail to respond, Earl Township may remove my name and information from their data base.  I understand that I am also responsible for notifying Earl Township if I change my address.

X _________________________________                 X________________________________

    (Signature of Authorized Person)                                                         (Witness)

X _________________________________                 X________________________________

                          Date                                                                              Relationship

Return Your Form To:
 Earl Township
517 N. RailraodAvenue
New Holland, Pa 17557

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