Emergency Assistance Request Form

If you or a loved one has a type of disability in which you might need assistance in an emergency, please fill out the form enclosed and return it to our local police department.

Emergency Assistance Request Form

CHALLENGES (please mark all that apply)

________ mobility impaired, bed bound

________ wheel chair capable

________ hearing impaired

________ oxygen/respirator use

________ transportation dependent

________ dialysis

________ mobility impaired, bed bound

________ Alzheimer/dementia

________ other (explain) ___________________________________________

________ year round resident

________ seasonal resident

Emergency Assistance Request Form

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