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2. Use this form to register as a deaf or hard of hearing individual in Amherst. Information from this form will be used by public safety officials for notifications in the event of an emergency.
4. First Name*
5. Last Name:*
7. Street Address (Ex: 4 Boltwood Avenue)*
9. Mobile Phone Number:
11. 
    Email Address
13. 
    TTY Phone Number
15. 
    Alternate Contact Person Phone Number
17. 
    In non-emergency events what is your preferred method of communications with the Town of Amherst?

    1. Email
    2. Text Message
    3. Video Phone Relay
    4. TTY Phone Relay
19. 
    Is it OK to contact you to verify the information you have submitted?*

    1. Yes
    2. No
21. 
    Comments Or Any Special Instructions for Contacting You
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field