Emergency Response Information Survey Question Title * 1. During an Emergency situation, information regarding the people, pets, livestock, facilities and equipment in your household may assist First Responders in decision-making and action planning. By checking the box below, you understand that the Stettler Regional Emergency Management Agency is collecting this information for its sole use and the information that you supply is done so on a voluntary basis. I Agree Question Title * 2. Please provide us with as much contact information as possible: Family Name Home Address Home Phone Work Phone Cell Phone Email Additional Contact Information Question Title * 3. People Living At Your Residence: Number of Adults Number of Children (Under 18) School or Child Care Provider Contact Information The following information is required if members of your household have special health needs or require special assistance. Please fill out one section for each individual requiring special needs or considerations. Question Title * 4. Person 1 Name of Affected Individual Description of Health Need Health Information Medication or Medical Equipment Grab and Go Bag Location Question Title * 5. Person 2 Name of Affected Individual Description of Health Need Health Information Medication or Medical Equipment Grab and Go Bag Location Question Title * 6. Person 3 Name of Affected Individual Description of Health Need Health Information Medication or Medical Equipment Grab and Go Bag Location Question Title * 7. Additional Persons Name of Affected Individual Description of Health Need Health Information Medication or Medical Equipment Grab and Go Bag Location Arrange for each family member to call, email or text the same out-of-town contact person in case of an emergency.Choose an out-of-town contact who lives far enough away they are unlikely to be affected by the same event. If you are new to Canada or have recently moved to a new area, make arrangements through friends, cultural associations or community organizations. Plan for PetsIn the case of an evacuation, remember household pets are not allowed in some public shelters or hotels. In case of an evacuation, prepare to take your pets with you to the home of a relative or friend, or take steps to identify pet-friendly hotels or pet boarding facilities in your area and further away from home.It may assist the First Responders to be aware of the type and number of pets that your residence hosts: Question Title * 8. List your pets below, indicating what type of animal they are and how many reside in your home. Animal 1 Animal 2 Animal 3 Additional Animals Question Title * 9. In the case of an evacuation, it may assist the Emergency Management Agency to understand how many and what types of livestock are located in the affected area: Animal Type and Approximate Number Animal Type and Approximate Number Animal Type and Approximate Number Animal Type and Approximate Number Animal Type and Approximate Number Question Title * 10. In the event our Emergency Management Agency is facilitating evacuations, it may be helpful for them to understand what types of rural facilities we have in our communities or on our farms and ranches, that could accommodate an evacuation of agricultural/farm animal operation. Please list any facilities you have that may be able to accommodate neighboring farm operations in an emergency evacuation. By providing this information, you will be added to a resource list to contact in the event the Emergency Management Agency is searching for local resources, and you will be able to advise availability. Type of Facility & Number of Livestock it could accommodate. Type of Facility & Number of Livestock it could accommodate. Type of Facility & Number of Livestock it could accommodate. Type of Facility & Number of Livestock it could accommodate. Question Title * 11. In the event our Emergency Management Agency is handling a local emergency, it may be helpful for them to understand what types of equipment might be available locally which could assist in an evacuation or emergency. Please list any equipment you have that could assist. By providing this information, you will be added to a resource list to contact in the event the Emergency Management Agency is searching for local resources, and you will be able to advise availability. Type of Equipment & Quantity Type of Equipment & Quantity Type of Equipment & Quantity Type of Equipment & Quantity Type of Equipment & Quantity Type of Equipment & Quantity Question Title * 12. Additional Comments or Information: Done