Resident Assistance Form

Resident Assistance Form

Please fill out this form if you are in need of special assistance.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact
Spouse, parent, child, etc.
Do any of the following apply to you?

Other
Please describe your functional and/or access needs
Other information that will help emergency personnel best assist you
By signing and submitting this form, I affirm that all information provided is true, accurate, and complete to the best of my knowledge and belief.

I acknowledge that submission of this information is voluntary and consents to the Town sharing such information with emergency personnel and agencies as necessary to provide assistance during emergencies or other public safety incidents.

I understands that the information submitted may be used by the Town of Galena, the Galena Volunteer Fire Company, the Kent County Sheriff's Office, and other emergency response agencies solely for emergency preparedness, response, welfare checks, and public safety purposes.
Signature
Date

MonthDayYear
Date
Should be Empty: