3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980 ph • (340) 718-4044 fax
3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980 ph • (340) 718-4044 fax Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph • (340) 774-3466 fax GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Office of the Commissioner Elder, Dependent Adult, and Disabled Person 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. Last Name: First Name: Primary Telephone: Secondary Telephone: Physical Address: City/Island: Zip Code: Email Address: Directions to the Address: (Include landmarks, color or home and all other recognizable features) 1.Are you Mobile? Yes, No 2. Are you on Medication? Yes, No 3. Do you live alone? …
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3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980 ph • (340) 718-4044 fax Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph • (340) 774-3466 fax GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Office of the Commissioner Elder, Dependent Adult, and Disabled Person 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. Last Name: First Name: Primary Telephone: Secondary Telephone: Physical Address: City/Island: Zip Code: Email Address: Directions to the Address: (Include landmarks, color or home and all other recognizable features) 1.Are you Mobile? Yes, No 2. Are you on Medication? Yes, No 3. Do you live alone? Yes, No Signature of Registrant: __________________________________________________________________ EMERGENCY CONTACT INFORMATION Last Name: First Name: Primary Telephone: Secondary Telephone: Email Address: SIGN