 |
|
 |
||
|
Neighborhood Roster Form : the first step of forming a neighborhood group after CORE I
Neighborhood Roster (Please print clearly)
Name:__________________________________________
Address:_____________________________________________________
Phone: Day___________________ Night__________________________
Other People in Household:________________________________________________ _______________________________________________________
Pets (name/type):______________________________________
Emergency Contact (friend/relative outside state): _____________________________ _____________________________ _____________________________ _____________________________
Special Emergency Skills/Equipment (ham radio, generator, camping equipment, tools (heavy/light) , 4 wheel vehicle, dirt bike, firewood) _______________________________________________________ _______________________________________________________
Special Emergency Skills/Training: (first aid/CPR, mechanic, carpentry, electrical, plumbing, child care, fire fighting, crisis-psychological) _______________________________________________________ _______________________________________________________
Special Needs (include any special concerns you would like help with i.e. elderly, non-ambulitory, special illnesses):________________ _______________________________________________________ _______________________________________________________
Profession:__________________________________________
Do you have a seismically safe, enclosed garage with extra storage space that we could use to store emergency supplies Yes No
In an emergency, I can house/sleep _______ people.
Return this form to: _________________________________________. |
 |
 |
 |
|
 |
 |
 |
 |
 |
 |
Home |  |
