Welcome to the Emergency Assistance Voluntary Registry!

Links

Office of Emergency Management & Communications

Online Voluntary Registry Form - My Profile

Please fill in the form if you need assistance in the event of an emergency, then click on the Save And Continue button to go to next step. Types of assistance may include evacuating a building or responding to an emergency call. If you don't want to add any information, click on the Cancel button.

* Required

User Name: *

(Between 6 and 16 characters)

Password: *

(Between 6 and 20 characters)

Confirm Password: *

First Name: *

Last Name: *

Middle Initial:

Birth Date:*

(ex) MM/DD/YYYY

Email Address is mandatory. Please check here for help. If you don't have an email address, check the box "I don't have an email address" below.

Email Address:*

I don't have an email address

Parent or Guardian :

(if applicable)

Home Address:*

House #

Direction

Street Name

Street Type

Apt./Room# :

Floor of Residence: Is there an elevator?:

Residence Type:

Name of Complex/ Subdivision/ Apt./ Facility:

Work/Other Address :

House #

Direction

Street Name

Street Type

Room# :

Home Phone Number:

(ex) 3121234567

Mobile Phone Number:

(ex) 3121234567

Other Phone Number:

(ex) 3121234567

For deaf and hard of hearing:

TTY :

VRS :

Text messaging:

(pager using email/text messaging)

Primary Language :

Secondary Language :

Do you know American Sign Language (ASL)? : Yes

Type of Disability:

Blind/Visual Impairment Deaf/Hard of Hearing
Mental/Cognitive Mobility disability

Assistive Devices:

Wheelchair Walker/Cane Service animal
Service Animal Type:

Electricity Dependent:

Ventilator Home oxygen system

Medical Needs:

Dialysis Feeding tube

Transportation:

          I am self-ambulatory     ambulatory with assistance
          I need a wheelchair-lift vehicle
          I am non-ambulatory and require stretcher transport

Other requirements :

Welcome to the Emergency Assistance Voluntary Registry!

Menu

Links

Online Voluntary Registry Form - My Profile