Yogaville-Buckingham Community Emergency Resilience — JOIN
Please fill out this form to help us prepare and respond effectively during emergencies.
Household Information
Name(s) of household members
*
Street address or location at Yogaville-Buckingham
*
Best phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Second phone number or email (optional)
Number of people in household
*
How to Reach You
Preferred communication methods
Phone
Community WhatsApp
GMRS radio
Other
Have you signed up for free Buckingham County Everbridge alerts?
Yes
Not yet
I'll do it
Not yet, need help
Are you interested in a GMRS radio?
Yes
Maybe
No
Volunteering
Would you serve as a zone captain or co-captain?
Yes captain
Yes co-captain
Maybe
Not now
Other ways you can help (select all that apply)
Door-to-door
CERT/first-aid
Defensible-space work days
Mapping/tech
Fundraising
Evacuation hosting/driving
Keep me informed
Functional Needs (Private/Optional)
Please indicate any functional needs (select all that apply)
Mobility/needs help evacuating
Medical equipment needing power
Needs a ride
Hearing/vision alert needs
Live alone, want check-in buddy
Pets/livestock
Prefer to discuss privately
Other
Anything else you'd like us to know about your household or needs?
I consent to sharing my functional needs responses with my zone captain only.
Yes, I consent
No, do not share
Submit
Should be Empty: