Emergency Assistance Survey

 

Let your local Fire Department know in advance if you might need any assistance during an emergency.

 

 

We are prepared to help you if you might need assistance during a public emergency.  If you or someone in your household might need help being notified of an emergency, sheltering-in-place, evacuating from home, or staying in a mass care shelter, please let us know. Help is available, but is best planned before an emergency happens.  Please fill out the information below and return this form to your local Fire Department. Your information will be kept strictly confidential and will not be shared. It will only be used to assist you during an emergency   ALL INFORMATION IS STRICTLY CONFIDENTIAL AND ONLY FOR USE DURING AN ACTUAL EMERGENCY.   I/this person will need help in the event of an emergency:

 

 

                        NAME:_____________________________________ DATE:___________________

                        ADDRESS:___________________________PHONE:_________________________

                        CITY & ZIP:__________________________ CELL PHONE:___________________

                        EMAIL:________________________________TTY:__________________________

 

 

Help Needed:   r       Translator (specify:___________) r       Need a ride r       Need a wheelchair accessible ride r       Need an ambulance for transportation r       Need individualized notification r       Need help with sheltering-in-place r       Service Animal (specify:_______)

I consider myself to be:   r       Deaf/hard of hearing r       Blind/low vision r       Wheelchair user r       Confined to bed r       Developmentally disabled r       Learning disabled r       Other (specify:_______________)

Comments:_________________________________________________________