Site
This Folder
Advanced Search
Special Populations Emergency Service Survey
This survey will assist Plymouth in determining your needs in the event of an emergency incident or evacuation.
Choose from the following:
No, I do not have special needs that will affect my ability to evacuate.
Yes, I have special needs that will affect my ability to evacuate.
Please provide the following information:
* indicates required information
Name
*
Address:
State:
Zip:
Home Phone:
Alt Phone:
Alternate Contact Person:
Alternate Contact Phone:
E-mail:
*
If you do have special needs in order to evacuate, please describe. (Examples: Medical Equipment, Personal Care Assistant, Service Animals, Other)