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Town of Woolwich
Emergency Services Assistance

In the interest of keeping all Woolwich residents safe during natural disasters such as the Ice Storm of 1998 or storms such as what we experienced with Hurricane Irene; the Town would like to compile a confidential list of those people in town who may require some assistance during such events.

If you are interested in being on this list, please PRINT this form
or
download the form (pdf).
Submit your information to the Town Office at your earliest convenience.


Name:_______________________________________________________

Address:_____________________________________________________

Phone numbers: Land Line______________ Cell Phone_______________

1. Medical Needs
Oxygen
Mobility issues
Live alone
Aged
Life Line or other medical alert system
Other _______________________

2. Family Members
Near by me
Able to check on me
My family member should be on your list- Their name _____________

3. Neighbors
Near by
Able to help me
In need of assistance - Their name _________________________

4. Cell Phone
Own a cell phone
Cell phone works from my home
Cell phone does not work from my home

5. What resources do you feel should be made available during times
of natural disasters? _________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

6. Any other information that you would like to share with us:
__________________________________________________________
__________________________________________________________
__________________________________________________________