Massachusetts Maritime Academy Evacuation & Emergency Form Question Title * 1. First Name: Question Title * 2. Last Name: Question Title * 3. Cell Number: Question Title * 4. Home Number: Question Title * 5. Email: Question Title * 6. You are: Student Staff Faculty Other (please specify) Question Title * 7. Emergency Contact: Name: Phone Number Question Title * 8. Address of Destination: Question Title * 9. Others with you: Question Title * 10. What is the year, make, and model of your automobile? Year Make (e.g., Ford) Model (e.g., Mustang) License Plate Done