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Online Emergency Registration Form

Registration: City of New Britain Access and Functional Needs Emergency Registry Form

 

A coalition of community partners has created a completely voluntary registry to supply emergency responders with vital information to assist people who may be vulnerable before, during or after an emergency. Enrollment in this program does not guarantee immediate help, but it allows emergency management officials the ability to plan for your assistance. Personal preparedness is essential; residents of New Britain should always be prepared to support themselves for 4 days after a disaster.

Required

Namerequired
First Name
Last Name
Email Addressrequired
Addressrequired
Cityrequired
Staterequired
Ziprequired
Phonerequired
Genderrequired
Date of Birthrequired
Primary Language Spoke?required
Emergency Contact Personrequired
Emergency Contact Person Relationshiprequired
Emergency Contact Person Phonerequired
During an emergency will you require assistance to leave your residence?required
Please select all boxes that most appropriately describes your needs or medical problems that you may face during an emergency or evacuation. Select all that apply.required
If Other, please specify: