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 – 716-839-6707.
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  • Emergency Contact for the above listed person
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  • (If Yes, please specify below)
  • (If Yes, please specify below)