Charlestown Shelter in Place Survey

Charlestown Shelter in Place Survey

Submit your location to the City of Charlestown, if you plan to Shelter in Place.
*This information does not serve as a guarantee of first responders visiting your home if you are sheltering in place for any event. If you have an emergency, please dial 911 for immediate available assistance.
Name*

First NameLast Name
Contact Number #1*
Contact Number #2*
Address*

Address of where you are Sheltering in Place

Street Address Line 2

CityState / Province

Postal / Zip Code
How many people are sheltering in place with you?*
Any one with you (including yourself) with disabilities or other access and functional needs?

YesNo
Do you have any pets with you?

YesNo
If yes, number of pets?
Comments:
Emergency contact outside this residence*
First and Last Name / Contact Number
Should be Empty: