Emergency Social Services Registration Form

EVACUATION INFORMATION
This form is for residents of the Municipality of Russell Binscarth who have evacuated their homes due to an emergency and cannot reach the Municipality by phone after regular hours.

The information you provide here is preliminary but ESSENTIAL. It helps the Municipality and Emergency Management Organization (EMO) track residents, estimate how many people have evacuated, confirm where they are staying, identify urgent needs, and support response planning.

Municipal or EMO staff will follow up during regular office hours if more information or clarification is needed.
Date of Evacuation

MonthDayYear
Date
Date of Registration

MonthDayYear
Date
EVACUEE INFORMATION
Primary Evacuee

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Age
Contact Method
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Are you the only Adult (over 18) in your household?
ADDITIONAL ADULT EVACUEE INFORMATION

Adults over 18 ONLY
Co-Primary Evacuee

First NameMiddle NameLast Name
Co-Primary Evacuee Birth Date

MonthDayYear
Co-Primary Evacuee Gender
Co-Primary Evacuee Age
Do you have any children/dependents under the age of 18?
DEPENDENT EVACUEE INFORMATION

Children under the age of 18 of whom you have custody, guardianship or formal legal authority
Dependent First Name
Dependent Middle Name
Dependent Last Name
Dependent Birthdate

MonthDayYear
Dependent Age
Dependent Gender
ADDRESSES
Address DURING the evacuation

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Regular Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SPECIAL CIRCUMSTANCES
PETS
Do you have pets?
Select the statement that best describes your current situation
Describe pets left behind
Include Species, Pet's Name, Location of their Food and any Medications, Pet's Temperament & Any other information that will assist emergency services workers in caring for your pet.
Accomodation Status
Pet's Needs

Other
HEALTH + MEDICAL

Do you have any medical conditions, health needs, or accessibility requirements that emergency services should be aware of to support you during evacuation ?
Medical Needs & Health Considerations

Other
INSURANCE

Answer the following questions to the best of your knowledge.
I Have Homeowners (or Renter's) Insurance
I Have Overland Flood Insurance
My signature certifies that I am the person identified as the Primary Evacuee in this form and that the information contained is accurate and correct to the best of my knowledge.
Should be Empty:

EVACUATION INFORMATION

EVACUEE INFORMATION

ADDITIONAL ADULT EVACUEE INFORMATION

DEPENDENT EVACUEE INFORMATION

ADDRESSES

SPECIAL CIRCUMSTANCES

PETS

HEALTH + MEDICAL

INSURANCE