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Who Should Complete This Registry Form?

You should complete this form if:
  • You are a temporary or permanent resident of Dutchess County, AND
  • You need assistance during an emergency and cannot manage on your own and/or you need other people to assist you if you must evacuate your home during an emergency, OR
  • You need first responders to understand any special needs you may have before entering your home to assist you.

How to Submit the Registry Form

Dutchess County offers many options for submitting this application. You can:
  • Complete the form online and click Submit at the bottom of the page.
  • Print and mail the Adobe Acrobat Portable Document Format (.PDF) version of your application to the address listed below using the U.S. Postal system.
  • Scan and submit your completed application to
  • Send us a clear, intelligible voice recording of the applicant’s information.
  • Schedule an appointment with someone who can personally interview you to complete the application.

For alternative means of filing an application that are within reasonable accommodation standards, or to ask additional questions about the Dutchess County Voluntary Access and Functional Needs Registry, please call (845) 486-2080.

Dutchess County Department of Emergency Response (DER)
392 Creek Road
Poughkeepsie, N.Y. 12601

Phone: (845) 486-2080
Fax: (845) 486-3998

* = Required


Personal Information



Address Information





Evacuation Plan


Please Tell Us About Yourself


Please select any/all that apply and may help first responders in assisting you.

I am:




If pregnant, please enter estimated due date.

I have:




I do not have:




I rely on the following:





I require the following medical equipment that is not easily transportable:



I understand that my participation in this registry is voluntary and all information submitted will be secured and held strictly confidential and used only for emergency purposes. I hereby request registration in the Dutchess County Voluntary Access and Functional Needs Registry.

By signing/submitting this form, I/legal guardian agree that my name and personal information provided therein this document will be added to the Dutchess County Access & Functional Needs Registry. I give the Dutchess County Department of Emergency Response (DER) authorization to share this information with other community emergency responders (such as Emergency Medical Services (EMS), Fire Departments, and area law enforcement) in the event of an emergency in order to facilitate an effective response. AFN Registry information will not be shared with others in non-urgent events. Information will be shared with United Way 211, who is a contracted agency with DER to facilitate aspects of this program and the notification process in the event of an emergency. By signing/submitting this application, you are granting emergency responders permission to enter your home following an emergency or disaster situation, if necessary, to assure your safety and welfare.