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Emergency Information Record

If you are a Halifax Senior and/or an individual with a disability that will require assistance in the event of an emergency evacuation or other emergency situation, please complete this form. The information provided will only be used by and shared with emergency and other authorized personnel. If you'd like to request more information or need to update to your record, please contact Darlene Regan, Council on Aging Director by calling (781) 293-7313 Ext. 135 or e-mail [email protected].

Resident Information
Emergency Contact Information
YesNo
Deaf or Hearing Impaired
Blind or Vision Impaired
Use of Walker / Mobility Resource (Wheel Chair, Crutches, etc.)
Confined to Bed
Cognitive Impairment
Need Assistance Getting onto a Van or Bus
Require Transportation Services / Assistance
Require Oxygen (Non-Powered Device)
Require Oxygen (Powered Device)
Own Pets
(if applicable)
(if applicable)
(if applicable) One Pet/Weight per line.