Contact Information

_{(Please fill out this entire section)}

Evacuation Assistance

If you answered yes to question 1:

Please provide the name, age and phone number (if different than yours) of the person or people in your household who might need assistance during an evacuation: _{Note: CVERA volunteers might contact your household during an evacuation to ascertain that the individual(s) have been safely evacuated and if they have not, CVERA would work to provide assistance. (Remember, there is a chance that you might not be around to help this individual in an emergency.)}

Please describe any potential issues that emergency personnel might encounter in accessing your home (for example: roads that are sometimes impassable, animals, locked gates).

If you answered yes to question 2:

Please provide any contact information that you have for the person(s) who you are concerned about (ie: name, physical address, phone number, mobile number).

Power Outages

If you answered yes to question 1:

Please provide the name and age of the person or people in your household who would need generator power during a power outage or evacuation:

If you answered yes to question 3:

Please provide the name of the person or people in your household who might need a space to cool down during a heat wave (especially if the heat wave occurs in combination with a power outage):

Miscellaneous

If you answered yes to question 1:

Please describe the equipment that you have:

If you answered yes to question 3:

Please describe the type of training and/or certificates:

Submit