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) 
Signature of Registrant: __________________________________________________________________ 
  
EMERGENCY CONTACT INFORMATION 
Last Name:   
First Name: 
Primary Telephone: 
Secondary Telephone: 
Email Address:   
 
SIGN