CH1 Neighborhood Skills and Equipment Inventory + Special Needs

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Please fill out this 5 minute form to let your Zone Captain, First Responders, & leaders know about any skills and equipment/supplies that you may be willing to share during a disaster.

Also, please let us know about any special help you may need: are there any disabled, elderly, or young children who may at times be home alone? (We will make checking on these individuals a top priority in the event of a disaster.)

When everyone plays their part, the community thrives. Thank you for strengthening our neighborhood!

Email (best one to reach you in an emergency)

Verify: re-type emergency contact email address (make sure they match, this form will not double check that automatically) You'll be able to go back and edit your responses once the form is completed.

Phone Number/s, Texting Y/N (best one to reach you in an emergency)

Name First/Last: *

Special help that my household may need. Please select all that apply.

Individual/s with disabilities

Elderly

Young children who may at times be home alone

Dialysis

Hearing Impairment

Homecare Assistance

Language Interpreter Needed

Life-sustaining Equipment

Mental/Cognitive Condition

Mobility Impairment

Refrigerated Medicines

Service Animal Required

Speech Impairment

Supplemental Oxygen Required

Vision Impairment/Blind

Other:

Please explain in more detail the name/s and type of help the above individual/s may need.

Other special needs or concerns?

Please list any hazards and their location on the property of which first responders should be aware. (Example: Chemicals, fuel, flammable substances, other hazardous materials.)

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