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Gates County
Home of Merchants Millpond State Park

Emergency Data Registry


Complete the Emergency Data Registry Form if you need assistance or if you can help during a disaster.  This form is to identify citizens that need special care in an emergency, ensure applicants are contacted during emergency situations, and maintain a volunteer database for assistance with disaster response.

All information on the Emergency Data Registry form will be maintained by Gates County Emergency Management, all Privacy Act Laws apply.

Attached Document or FileEmergency_Data_Registry.pdf  
Attached Document or FileCondado_De_Gates_Direccion_de_emergencias_y_desastres_registro_de_datos_en_caso_de_emergencia.pdf  
First Name:
Last Name:
Date of Birth:
Home Phone Number:
Cell Phone Number:
Email Address:
Emergency Contact:
Emergency Contact Phone Number:
Emergency Contact 2:
Emergency Contact 2 Phone Number:
General Medical/Special Needs:
In Case of Emergency- Will You...?: Stay At Home
Evacuate to a Shelter
Stay with Family or Others
Evacuate Out of the Area
Required Medical Equipment: Wheel Chair
Sight Assistance Animal
Transportation is Needed
I CAN HELP! In the event of an Emergency, I would be willing to assist Emergency Management Officials by:: Give a neighbor(s) a ride
Be on a clean up crew
Assist with food-water-ice
offer myself as an interpreter
Special abilities or assets that you are willing to volunteer::
Enter the letters and numbers exactly as shown into the "Security Code" field:
*Security Code:

200 Court Street, Gatesville, NC 27938, (252) 357-2411