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Amherst CERT - Special Assistance Registration Form

  1. Amherst_CERT.png
  2. Please be aware that all information will be kept confidential and only used by town officials for planning purposes and emergency responders in time of need.
  4. Recieve Text (SMS) Messages?
  5. About Your Household - DO YOU OR A MEMBER OF YOUR HOUSEHOLD:
  6. 1.) Have a physical or disability or mibility problem that would interfere with evacuating your home or going to an Emergency Services Facility?
  7. 2.) Take medication for diabetes?
  8. 3.) Have a chronic medical condition that requires medication?
  9. 4.) Take a medication that if you ran out of that medicine it would be terminal?
  10. 5.) Have a compromised immune system?
  11. 6.) Require supplemental oxygen?
  12. 7.) Have a severe hearing or vision problem?
  14. Leave This Blank:

  15. This field is not part of the form submission.