200__ – FAMILY PLAN

Please Print

Name: _______________________________________ Age: _________ Gender:  M  F

Address: ____________________________________________ Unit: _______

City: __________________________________________ State: ______  Zip: _______

Home Phone: ___________________           Cell Phone:  ____________________

Please list the              Name__________________________ Age______ Gender:  M  F

       names of             Name__________________________ Age______ Gender:  M  F

       people in             Name_________________________ Age_______ Gender:  M  F

    your home.             Name_________________________ Age_______ Gender:  M  F

(if more space is needed, attach a separate page with names, age, and gender)

1.   Flood Zone/Evacuation Level of your residence (circle):  A   B   C   D   E

non-evac area   not sure

      Do you live in a mobile home?   Yes  No

2.   In the event you are forced to evacuate you and your family intend to do?

      ___ haven't made any plans

     ___leave the city – to go where: _________________________________________
          _______________________________________________Phone:____________

     ___stay with relatives/friends – Address:___________________________________
          _______________________________________________Phone:____________

     ___go to a motel – where:______________________________________________
           ________________________________________________________________

     ___go to a Red Cross Shelter – Location:__________________________________
          ________________________________________________________________

     ___I am pre-registered at the following Special Needs Shelter*:________________
           _______________________________________________________________

* If you do have special needs and haven’t pre-registered, do you need additional information?  Yes   No

** If you are home bound and require special assistance with transportation to a shelter, you should contact your local fire department soon to determine if they could help you should there be a disaster. 

3. Information of a contact person outside the area in case we are unable to locate you:*

    Name____________________________________________________________

    Address__________________________________________________________

    Home Phone (with area code) _________________   Cell Phone______________

* In an emergency, this information could be beneficial to the local county emergency manage­ment agencies or your out-of-town loved ones who could be concerned about your safety and location.

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