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For vulnerable seniors and persons with disabilities
Your Phone number:
Mailing Address (
Check if same as physical)
Name and phone number of an emergency contact person who does not live with you:
What conditions makes you vulnerable to a disaster?
Dementia / Alzheimer's
Medical life support (describe on right)
Mobility impairment (list mobility aids on right)
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.
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632 West 6th Avenue, Anchorage, Alaska 99501