Town Emergency Alert Form(it's like a reverse 911) keeping you updated with Town Emergencies (For Town Official Use Only - ALL information shall be kept confidential) I/This person allows messages to be sent to their phone in the event of a Town-declared emergency: Name: * Street Adress: * Phone: * Alternate Phone: TTY: Email Address: Please check EACH item that applies to you: I am challenged by: Deaf or Hearing Impaired Blind or Vision Impaired Person in Wheelchair Confined to Bed Medical needs requiring electricity Other Please specify: Help needed: Need a ride Need a Wheelchair Accessible Ride Need an Ambulance Need Individualized Notification Need help Sheltering in Place Other Please specify: I share my home with the following companion animals: Dog Cat Bird Other Please specify: Person we can notify to help you in case of emergency: Name: Relation: Address: Phone (Home): Alternate Phone: Email Address: Leave this field blank