Upper Bucks Regional EMS Special Needs Registry

Upper Bucks Regional EMS, Inc. and its local Emergency Management Agencies (EMA) have developed a registry for Upper Bucks County residents to notify us in advance of any health conditions or special needs that may require specialty services during a disaster. By filling out this form, you will permit UBREMS to share your information with local and state emergency responders, such as your town/city police, fire department, emergency management agencies and its affiliates/entities and staff. The information that you provide may help emergency responders meet your needs during an emergency.

INSTUCTIONS: To be included in this registry, please complete the following form. If you have any questions or would like to receive a paper version of this form, please call (610)847-2165. If you cannot fill out this form on your own, please have a family member or caregiver complete the form and submit it on your behalf. Please complete one form for each individual person.

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    General Information

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    Emergency Contact Information

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