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
Format: (000) 000-0000.
Contact Number #2
Format: (000) 000-0000.
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?
Do you have any pets with you?
If yes, number of pets?
Comments:
Emergency contact outside this residence
First and Last Name / Contact Number
Should be Empty: