Personal information First name * Last Name * Address * City * Province * - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutPrince Edward IslandSaskatchewanOntarioQuébecYukon Postal code * x1x 1x1 Home phone * 111 888-8888 Cell phone 111 888-8888 E-mail Reason you need assistance Select your reason: * Deaf or hearing impaired Blind or vision impaired Motor disability Intellectual disability or invasive developmental disability Reduced mobility Other (such as degenerative illness) I consent to being registered in the Emergency Evacuation Assistance Program. If the request was made by a legal guardian, the person must be informed of his or her registration. * Yes No Name of legal guardian (if applicable) How would you like for us to communicate with you about updating your personal information each year? * Phone E-mail Person to contact in the event of an emergency (someone with a different address than yours)This person may be advised of your whereabouts if you are evacuated. First name * Last Name * Home phone * 111 888-8888 Cell phone 111 888-8888 Leave this field blank Submit
