Evacuation Details:

Town of Lynn Lake

Evacuation Registration Form
Date of Evacuation

MonthDayYear
Date
Municipality/City/Town of Residence
Name

First NameLast Name
Year of Birth
Phone number
Email Address(es)
Co-Registrant Name

First NameLast Name
Year of Birth
A separate registration form is required for any children 18 years or older
Please list all children under 18 and their birth years
Please list the number and type of pets that you are evacuating with e.g., 2 cats, 1 dog, etc.
Please list the number and type of pets that you are leaving behind e.g., 2 cats, 1 dog, etc.
Please list any special circumstances that need to be considered for you and your family to evacuate successfully.
Permanent Mailing Address (if different from above)
Temporary Mailing Address During Evacuation
What city/town are you evacuating to?
Mode of transportation

Personal VehicleBusFlightOther
If other please specify
What type of accommodations will you be staying in while evacuated?

UnknownFriends/FamilyHotelOtherShort-Term Rental
Please explain if 'Other'
Is there anything else we should know?
This information is collected under the authority of The Emergency Measures Act and is necessary for administrative purposes. It may be shared with other public bodies, organizations and/or agencies to enable the provision of emergency services. Disclosure of personal information is subject to the provision of the Freedom of Information and Protection of Privacy Act. If you have any questions, please contact the Town of Lynn Lake by email at info@lynnlake.ca or by phone at 204-356-2418.
Signatures:
Submitted by

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

A separate registration form is required for any children 18 years or older

Signatures: