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2. 
6. 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.
10. PERSONAL INFORMATION
14. First Name:
15. Last Name:
16. Date of Birth:
    Date of Birth:
18. Street Address:
19. Zip Code:
21. Preferred Phone:
22. Cell Phone:
23. Recieve Text (SMS) Messages?

    1. Yes

    1. No
27. About Your Household - DO YOU OR A MEMBER OF YOUR HOUSEHOLD:
31. 1.) Have a physical or disability or mibility problem that would interfere with evacuating your home or going to an Emergency Services Facility?

    1. Yes

    1. No
32. If yes please explain
34. 2.) Take medication for diabetes?

    1. Yes

    1. No
35. If yes please explain
37. 3.) Have a chronic medical condition that requires medication?

    1. Yes

    1. No
38. If yes please explain:
40. 4.) Take a medication that if you ran out of that medicine it would be terminal?

    1. Yes
    2. No
41. If yes please explain:
43. 5.) Have a compromised immune system?

    1. Yes

    1. No
44. If yes please explain:
46. 6.) Require supplemental oxygen?

    1. Yes

    1. No
47. If yes please explain:
49. 7.) Have a severe hearing or vision problem?

    1. Yes

    1. No
50. If yes please explain:
52. 8.) If you have any other information that will help emergency personnel or city officials better assist you in an emergency such as a flood, natural disaster or disease outbreak, please use the lines below to add in the additional information. Please be aware that all information will be kept confidential and only used by city officials for planning purposes and emergency responders in time of need:
56. SUBMIT YOUR REGISTRATION FORM
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60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

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