Emergency Preparedness

2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Fax Number
14. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
16. Electronic Signature*
18. QUESTION 1

    Do you have an Oxygen Concentrator, CPAP, Electric Recliner, Medical Bed or any other Medical equipment that the emergency personnel need to be made aware of that requires electricity?

    
    

19. Answer*
21. Question 2

    Do you have a Generator?

22. Answer*
24. Question 3

    If you were to go without power, how long could you sustain with out electricity or a generator?

25. Answer*
27. Question 4

    How many days worth of food, medicine and water do you keep on hand in case of bad weather?

28. Answer*
30. Question 5

    How do you Communicate with other?  (Cell phone, land line, Computer)

31. Answer*
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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