Town of Woolwich
Emergency Services Survey

In the interest of keeping all Woolwich residents safe during natural disasters such as the Ice Storm of 1998 or storms such as what we experienced with Hurricane Irene; the Town would like to compile a confidential list of those people in town who may require some assistance during such events.

If you are interested in being on this list, please PRINT this form and answer the questions below.
Submit your survey to the Town Office at your earliest convenience.

Name:_______________________________________________________
Address:_____________________________________________________
Phone numbers: Land Line______________ Cell Phone_______________

1. Medical Needs
□ Oxygen
□ Mobility issues
□ Live alone
□ Aged
□ Life Line or other medical alert system
□ Other _______________________

2. Family Members
□ Near by me
□ Able to check on me
□ My family member should be on your list- Their name _____________

3. Neighbors
□ Near by
□ Able to help me
□ In need of assistance - Their name _________________________

4. Cell Phone
□ Own a cell phone
□ Cell phone works from my home
□ Cell phone does not work from my home

5. What resources do you feel should be made available during times
of natural disasters? _________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

6. Any other information that you would like to share with us:
__________________________________________________________
__________________________________________________________
__________________________________________________________