Storm Shelter Registration Form
This information is to be used by emergency personnel only in the event of an emergency. This registration helps to let us know where you may be in the event of a natural disaster if you needed to be rescued. This shelter form does include basements.
First and Last Name:
*
First Name
Last Name
Cell Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Physical Address (No PO Boxes)
*
Street Address
Apartment or Building Number
City
State / Province
Postal / Zip Code
Number of People in Home:
*
Number of People with Disabilities:
Number of People Non-Ambulatory:
Cannot walk or move without full assistance, generally wheel-chair or bed bound.
Number of People on Oxygen:
Special Considerations: If you have any special needs please that we need to be aware of in rendering first aid and rescue, list them here.
Location of Shelter
*
Basement
Front Yard
Back Yard
Garage
Other Location of Shelter:
Type of Shelter
*
Basement
Yard / Detached from Home
Garage
Safe Room
Other Type of Shelter:
Construction Type
*
Metal
Poured Concrete
Concrete Block
Other Construction Types:
Please Read and e-sign:
Homeowner/Occupant Name:
*
Homeowner/Occupant Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: