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First Name:Last Name:Home Address:City:Zip:Your Phone number:What is your primary condition that makes you vulnerable to a disaster? (Examples: Insulin-dependent, live alone without support,vision-impaired, need oxygen, wheelchair user, etc.)Name and phone number of an emergency contact person who does not live with you:Name:Phone:Please check the box next to the type of assistance you may require during an emergency:I may need transportation assistance if an evacuation is requiredI would like someone to call me or check in on me after a disasterPlease select the fire station closest to your homeStn. 1: 122 E. 4th Ave. (4th & Barrow)NorthsideStn. 3: 1100 Airport Heights RdStn. 5: Spenard & McRaeStn. 4: Tudor & MacinnesEastsideStn. 6: DeBarr & PattersonStn. 11: Bottom of Eagle River RdStn. 14: 4501 Campbell Airstrip RdSouthsideStn. 7: Jewel Lake & W. 88thStn. 8: 6151 O'Malley RdStn. 9: 1148 Huffman Rd.Stn. 10: Top of Rabbit Creek RdStn. 12: New Seward & DimondStn. 15: 11301 Southport DrOutside AnchorageGirdwood Fire and RescueChugiak-Eagle River VFDI authorize this information to be maintained confidentially at the Anchorage Office of Emergency Management and the Fire Department for use only during an emergency that may affect me or my home. Information submitted on this form will not be shared with unauthorized persons or organizations. Authorized release will only occur in a disaster or emergency situation to effect delivery of aid to the registered party.

DISASTER REGISTRY
For vulnerable seniors and persons with disabilities