FHA HSS Voluntary Emergency Information Registration

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VOLUNTARY EMERGENCY INFORMATION REGISTRATION

This form is for any resident of Fearrington Village who is (a) new to the Village or (b) whose situation has changed, to provide information that can be used by local Emergency Response Units in the event of emergencies and natural disasters. This form allows you to identify individuals you wish to be notified in the event of your incapacitation due to injury or illness. If a resident of your household has any special needs that need to be considered in the event of an emergency, you should register with Chatham County Emergency Services. This form also allows you to register resources or training that you have that could help the community in the event of a natural disaster. Thank you for your cooperation.
Date This Form Was Completed *

Month Day Year
Basic Household Information
Your Street Number *
Your Street Name *
Your Fearrington Post Number *
Your Home Phone Number *
If your home is vacant on a regular basis, indicate the typical beginning and ending dates.
Resident(s)
Your Full Name *

First Name Last Name
Your Cell Number (if any)
Your E-mail
Your Work Phone Number (if any)
Resident #2 (if any) Full Name

First Name Last Name
Resident #2 (if any) Under Age 18?

NO Yes
Resident #2 Cell Number (if any)
Resident #2 E-mail (if any)
Resident #2 Work Phone Number (if any)
Resident #3 (if any) Full Name

First Name Last Name
Resident #3 (if any) Under Age 18?

NO Yes
Resident #3 Cell Number (if any)
Resident #3 E-mail (if any)
Resident #3 Work Phone Number (if any)
Emergency Contact Information
Full Name of Emergency Contact #1

First Name Last Name
Phone Number for Contact #1
Address for First Contact

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Full Name of Emergency Contact #2

First Name Last Name
Phone Number for Contact #2
Address for Contact #2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Full Name of Emergency Contact #3

First Name Last Name
Phone Number for Contact #3
Address for Contact #3

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Resources and/or Training You May Have That Could Help You, Your Family, and the Community in the Event of a Severe Storm or Other Disaster.
Please indicate whether you have any of the following safety items or arrangements in your home. Check all that apply.

I/we have the RED FILE OF LIFE magnetic sleeve (with a completed form inside) on the side of (or near) our refrigerator. I/we have an AED (Automated External Defibrillator) device in our home. I/we have a KNOX BOX exterior key safe (installed by Fearrington Cares for use by emergency responders) next to our front door. Our household is prepared to survive three days without an external supply of water, food, medicines, and essential supplies for residents and pets (if any). Our household has developed an emergency plan that includes evacuation driving routes. My/our neighborhood has an emergency calling and/or support network.
Do you have any of the following skills or training to assist the community in recovering from a community emergency? Check all that apply.

CPR/First Aid Training Prior CERT Training Physician Physician's Assistant Nurse EMT Training Nurse Practioner Red Cross Shelter
Do you own any of the following types of vehicles that you would be willing to use to assist in recovering from a community emergency? Check all that apply.

4-Wheel Drive Vehicle Pick-Up/Other Truck Station Wagon/SUV Car
Check items that you have, which you would be willing to share in the event of a community emergency. Check all that apply.

Gas Generator Gas/Propane Grill Propane Heater Kerosene Heater Electric Heater Long Outdoor Extension Cord Chain Saw (Electric) Chain Saw (Gas) Bow Saw Police Scanner CB Radio Battery Operated Radio Battery Operated TV Step Ladder Extension Ladder Dolly Wheelbarrow Heavy Duty Rope Chains Tarp OTHER item(s) use textbox below
Other Item(s)
REQUIRED TO SUBMIT: I/we consent and give permission for the use of the above information by the Fearrington Homeowners Association or FHA (and its agents). I/we have carefully read this form and agree to hold harmless all parties who are entitled to use this information. *

YES
VERY IMPORTANT -- READ THIS BEFORE SUBMITTING!

After submitting, you will also soon receive a receipt containing all the replies you entered on your form. The subject line on that emailed receipt will read: "SAVE THIS MESSAGE. Your FHA HSS Registration and Hot-Link to Edit it at Any Time"
Save Your Email Receipt

Be sure to save that receipt in your email mailbox. IT IS YOUR "TICKET" to return at any time to update or revise your replies, which you should do at least annually or when changes occur.
How To Update Your Form

At the top of that receipt, you will see a blue underlined "Edit Submission" hot-link, which is how you can adjust your content later. Whenever you use that link and re-submit the form, your data will be automatically updated.
Should be Empty:

VOLUNTARY EMERGENCY INFORMATION REGISTRATION

Basic Household Information

Resident(s)

Emergency Contact Information

Resources and/or Training You May Have That Could Help You, Your Family, and the Community in the Event of a Severe Storm or Other Disaster.

VERY IMPORTANT -- READ THIS BEFORE SUBMITTING!

Save Your Email Receipt

How To Update Your Form