EOC registration

DISASTER REGISTRY
For vulnerable seniors and persons with disabilities

First Name: Last Name: Your Phone number:
Home Address: City: Zip:

Mailing Address ( Check if same as physical)
Mailing Address: Mailing City: Mailing Zip:

Name and phone number of an emergency contact person who does not live with you:

Name: Phone: Relationship:

What conditions makes you vulnerable to a disaster?

Cognitive impairment
Physical disability
Mental illness
Hearing impairment
Visual impairment

Developmental Disability
Dementia / Alzheimer's
Renal dialysis
Medical life support (describe on right)
Mobility impairment (list mobility aids on right)

Comments

I authorize this information to be maintained confidentially by the Anchorage Office of Emergency Management for use only during an emergency that may affect me in my home. Authorized release will only occur during an emergency to effect delivery of aid to the registered party or to verify registration. Although the Municipality will make every effort to assist you in a timely manner, no guarantee is implied by your registration.

ADA Compliance Privacy Statement & Disclaimer Employee Search eNewsletter RSS

OFFICIAL WEB SITE OF THE MUNICIPALITY OF ANCHORAGE, ALASKA
632 West 6th Avenue, Anchorage, Alaska 99501