Personal information First name Last Name Address City Province - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal code x1x 1x1 Home phone 111 888-8888 Cell phone 111 888-8888 E-mail Reason you need assistance Select your reason: Deaf or hearing impaired Blind or vision impaired Motor disability Intellectual disability or invasive developmental disability Reduced mobility Other (such as degenerative illness) I consent to being registered in the Emergency Evacuation Assistance Program. If the request was made by a legal guardian, the person must be informed of his or her registration. Yes No Name of legal guardian (if applicable) How would you like for us to communicate with you about updating your personal information each year? Phone E-mail Person to contact in the event of an emergency (someone with a different address than yours) First name Last Name Home phone 111 888-8888 Cell phone 111 888-8888 This person may be advised of your whereabouts if you are evacuated. Submit Leave this field blank
