{"id":72,"date":"2016-07-29T15:19:59","date_gmt":"2016-07-29T19:19:59","guid":{"rendered":"http:\/\/172.16.1.215\/ema\/?page_id=72"},"modified":"2016-07-29T15:19:59","modified_gmt":"2016-07-29T19:19:59","slug":"special-needs-registration-form","status":"publish","type":"page","link":"https:\/\/www.coshoctoncounty.net\/ema\/special-needs-registry\/special-needs-registration-form\/","title":{"rendered":"Special Needs Registration Form"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f71-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"71\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/ema\/wp-json\/wp\/v2\/pages\/72#wpcf7-f71-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"71\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f71-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p>Name (required)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n<\/p>\n<p>Phone (required)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-phone\" \/><\/span>\n<\/p>\n<p>Address (required)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-address\" \/><\/span>\n<\/p>\n<p>City (required)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-city\" \/><\/span>\n<\/p>\n<p>Township (required)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-township\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-township\" \/><\/span>\n<\/p>\n<p>Sex (required)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-sex\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"your-sex\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\n<\/p>\n<p>Residence (required)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-residence\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"your-residence\"><option value=\"House\/Duplex\">House\/Duplex<\/option><option value=\"Apartment\/Condo\">Apartment\/Condo<\/option><option value=\"Mobile Home\">Mobile Home<\/option><option value=\"Group Home\">Group Home<\/option><\/select><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-floor\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"your-floor\"><option value=\"1st Floor\">1st Floor<\/option><option value=\"Upper Floor\">Upper Floor<\/option><\/select><\/span>\n<\/p>\n<p>Kind of Assistance\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-assistance\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"your-assistance[]\" value=\"Bedfast\" \/><span class=\"wpcf7-list-item-label\">Bedfast<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"your-assistance[]\" value=\"Wheel Chair\" \/><span class=\"wpcf7-list-item-label\">Wheel Chair<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"your-assistance[]\" value=\"Oxygen\" \/><span class=\"wpcf7-list-item-label\">Oxygen<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"your-assistance[]\" value=\"Medications\" \/><span class=\"wpcf7-list-item-label\">Medications<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"your-assistance[]\" value=\"Homebound\" \/><span class=\"wpcf7-list-item-label\">Homebound<\/span><\/span><\/span><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-assistance-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-assistance-other\" \/><\/span>\n<\/p>\n<p>Pets (required)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-pets\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"your-pets\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/p>\n<p># of cats: <span class=\"wpcf7-form-control-wrap\" data-name=\"your-pets-cats\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-pets-cats\" \/><\/span>\n<\/p>\n<p># of dogs: <span class=\"wpcf7-form-control-wrap\" data-name=\"your-pets-dogs\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-pets-dogs\" \/><\/span>\n<\/p>\n<p>other pets<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-pets-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-pets-other\" \/><\/span>\n<\/p>\n<p># of other pets: <span class=\"wpcf7-form-control-wrap\" data-name=\"your-pets-other-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-pets-other-number\" \/><\/span>\n<\/p>\n<p>Number of persons requiring assistance at this location\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-number-persons\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-number-persons\" \/><\/span>\n<\/p>\n<p>Emergency Contact (not living with you)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-na\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"your-emergency-contact-na[]\" value=\"N\/A (if emergency contact is not applicable the below fields are not required)\" \/><span class=\"wpcf7-list-item-label\">N\/A (if emergency contact is not applicable the below fields are not required)<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Name\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-emergency-contact-name\" \/><\/span>\n<\/p>\n<p>Address\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-emergency-contact-address\" \/><\/span>\n<\/p>\n<p>City\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-emergency-contact-city\" \/><\/span>\n<\/p>\n<p>Phone Daytime\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-phone-day\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-emergency-contact-phone-day\" \/><\/span>\n<\/p>\n<p>Phone Evening\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-phone-evening\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-emergency-contact-phone-evening\" \/><\/span>\n<\/p>\n<p>Cell Phone\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-cell-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-emergency-contact-cell-phone\" \/><\/span>\n<\/p>\n<p>Email Address\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-emergency-contact-email\" \/><\/span>\n<\/p>\n<ul>\n\t<li>\n\t\t<p>Registration does not eliminate the individual from taking steps to insure their personal preparedness, health and safety. Completion of this form does not promise evacuation assistance or obligate first responders to evacuation service. This information will be used in a best effort approach to ensure resident's safety and comfort.\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>When your condition or location change, it is your responsibility to advise EMA of the change by completing another copy of this form.\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>By submitting this form, I am consenting to release this information to first responders, (Fire, Law Enforcement, Emergency Medical Service, Public Health, County Officials and Emergency Management Agency).\n\t\t<\/p>\n\t<\/li>\n<\/ul>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":36,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"ngg_post_thumbnail":0,"footnotes":""},"class_list":["post-72","page","type-page","status-publish","hentry","post-preview"],"_links":{"self":[{"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/pages\/72","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/comments?post=72"}],"version-history":[{"count":1,"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/pages\/72\/revisions"}],"predecessor-version":[{"id":73,"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/pages\/72\/revisions\/73"}],"up":[{"embeddable":true,"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/pages\/36"}],"wp:attachment":[{"href":"https:\/\/www.coshoctoncounty.net\/ema\/wp-json\/wp\/v2\/media?parent=72"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}