Information for Special Assistance in Event of Emergency
Please enter information below for residents who will need assistance during an emergency situation. All information is kept confidential and shared only with Emergency Responders.
Name of Person in Need of Assistance
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Name of Emergency Contact
*
First Name
Last Name
Emergency Contact Email
*
example@example.com
Emergency Contact Phone Number
*
Please enter a valid phone number.
Type of disability
Please Select
Disabled
Hard of Hearing
Legally Blind
Legally Deaf
Other
Of Other, please explain
Type of special equipment used
Please Select
None
Wheelchair
Walker
Guide Dog
Lift Van
Other
Of Other, please explain
Other Situations
Does resident have a Daytime Attendant?
Please Select
Yes
No
If yes, enter Day Attendant Name & Phone Number
First Name
Last Name
Day Attendant Phone Number
Please enter a valid phone number.
Does resident have a Night Attendant?
Please Select
Yes
No
If yes, enter Night Attendant Name & Phone Number
First Name
Last Name
Night Attendant Phone Number
Please enter a valid phone number.
Is there a neighbor nearby who can assist in the event of an emergency?
Please Select
Yes
No
If yes, enter Neighbor's Name & Phone Number
First Name
Last Name
Neighbor Phone Number
Please enter a valid phone number.
Questions
Submit
Should be Empty: