Emergency Contact Information

EMERGENCY CONTACT FORM

Please create a separate submission for each individual resident.
Resident’s Name*
Enter First & Last Name for ONLY one person
Address*
Gallery Street Address
Email Address*
example@example.com
Phone Number
A mobile phone number is preferred, however a land line is OK.
Alternate Phone Number, if any
Enter either mobile number or land line.
1st Emergency Contact*
First & Last Name
Relationship to Resident*
Address
Phone Number*
Alternate Phone Number
2nd Emergency Contact
First & Last Name
Relationship to Resident
Address
Phone Number
Does anyone in The Gallery have a key or key code to your house?*

YesNo
If yes, who in The Gallery has a key or key code to your house?
First & Last Name
Does anyone in The Gallery have your emergency contact information?*

YesNo
If yes, who in the Gallery has your emergency contact information?
First & Last Name
Safety Tip: If you may need assistance to evacuate in the event of an emergency, make sure at least 2 neighbors are aware of your situation.
I shall be responsible for keeping the information contained on this emergency contact form current, and will notify the Gallery Office when the information on this form should be changed.

I release members of the Board of Directors, management and the Talega Gallery Community Association from any liability or responsibility with the dissemination of this information.

I understand this information will only be shared by Gallery Office staff, and only under verifiable emergency conditions.

The HOA makes no guarantee that having emergency contact information will ensure notification in all circumstances.
Signature (Use your mouse or finger)*

Clear
Today's Date*

MonthDayYear
Date
Update Date

MonthDayYear
Date
22 Calle Galeria San Clemente, CA 92673 (949) 361-4685

Talega.gallery@seabreezemgmt.com
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EMERGENCY CONTACT FORM