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Emergency Response Data Form
Everybody has need but do the right people know what yours are? IF you or someone in your household has a disability or a special medical need, the people whose job it is to respond when you call for help in an emergency need to know. Whether it affects your entire community, your street or just your home, Seconds can make a life-or-death difference. That’s why we encourage you to take a minute to fill out the form below. Having specific details about your special situation will significantly help us help you. For more information contact – 716-631-7122.
Name
*
First
Last
Street Address
*
Apt. No.
Town
*
State
*
Zip
*
Type of Residence (please check one)
Single family home
Assisted living facility
Senior housing complex/facility
Phone # of listed person
*
###
-
###
-
####
Email
How many people live in the household?
Age
Date of Birth
MM
/
DD
/
YYYY
Your Language (if not English)
Emergency Contact for the above listed person
Name
*
First
Last
Relationship
Primary Phone #
*
###
-
###
-
####
Secondary Phone #
###
-
###
-
####
Are you confined to your bed?
Yes
No
Are you on constant oxygen?
Yes
No
Are you on dialysis?
Yes
No
Are you visually impaired?
Yes
No
Are you hard of hearing or deaf?
Yes
No
Are you on life support?
Yes
No
Do you live alone?
Yes
No
Do you have your own transportation?
Yes
No
Do you use a wheelchair?
Yes
No
Do you have a service animal?
Yes
No
Can you walk with assistance?
Yes
No
Do you have mental health concerns?
Yes
No
(If Yes, please specify below)
Do you have an intellectual disability?
Yes
No
(If Yes, please specify below)
Additional Information
