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rHealth    &
Social Services

 
The City of Bridgeport, CT, and community agencies serving Special Populations, invites you to complete this survey to help determine your needs in the event of a disaster or evacuation.

 r

 EVACUATION REGISTRATION

Survey to help determine your needs in the event of a disaster or evacuation
Name:
Address where you live:
ZIP Code:
Home phone number:
Alternate phone number:
Alternate contact person:
Alternate contact phone:
In the event of a disaster do you have a plan to evacuate?
If YES, what transportation do you plan to use?
Do you have SPECIAL NEEDS that will affect your abiltiy to evacuate?
If YES, please check what type of needs:

 SUBMIT
 

  If you have any questions, you may call 203-576-xxxx or
TTY phone: 203-576-xxxx, for further information

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