People with Disabilities Form

Please fill out this questionnaire. Your cooperation will help us in making proper arrangements if it becomes necessary for you to be evacuated during an emergency of any kind.

Please provide the following information:
Name  
Address
Town/City
Home Phone  
Date of Birth
Primary Disability  
Secondary Disability

Name and phone number of a local relative or person who lives 
near you who should be contacted in an emergency:
Name  
Home Phone  

Choose one of the following options:

   If other, specify:

Select any of the following options that apply:

Are you blind or partially sighted?
Are you deaf or hearing impaired?
Can you get from you house?
Can you get to a bus stop unassisted?
Are you completely bedridden?
Do you have your own transportation?
If not, can you arrange a ride with a nearby person?

NOTE: This form submits directly to the Fire Training Center and is strictly confidential.