CHIPMAN WANTS TO BE READY

SHOULD THERE BE AN

EMERGENCY SITUATION

(ice storm, chemical spill, power outage, etc.)

YOU CAN HELP!

All information is confidential and will be used only to prepare our resource information in case of emergency.

NAME:            ________________________________

ADDRESS:      ________________________________

                         ________________________________

                         ________________________________

PHONE:          ________________________________

CELL:               ________________________________

EMAIL:           ________________________________

IS THERE SOMEONE AT YOUR HOUSE THAT WOULD REQUIRE SPECIAL ASSISTANCE IN TIME OF AN EXTENDED POWER FAILURE I.E. OXYGEN, DIALYSIS, MAXI MIST, ETC?

      NAME ____________________________________________

       AILMENT/SITUATION _______________________________________________________________

NUMBER OF PEOPLE IN HOUSEHOLD:               _______________

WHAT IS YOUR MAIN SOURCE OF HEAT?         _______________

DO YOU HAVE BACKUP HEAT?                            _______________

DO YOU OWN:

            GENERATOR _______TYPE  __________WATTAGE________

            KEROSENE HEATER            __________

            PORTABLE PUMP     __________

            PORTABLE WELDING MACHINE  __________

            CB RADIO      __________

            SCANNER      __________

            TRUCK           ____    BOAT _____     ATV _____  SKIDOO _____

            SKIDDER OR BACKHOE     __________

            OTHER EMERGENCY EQUIPMENT           __________

            PROPANE TANKS    __________

DO YOU HAVE MEDICAL EXPERIENCE?

                        CPR?               __________

                        FIRST AID      __________

                        NURSING       __________

                        OTHER           __________

ARE YOU WILLING AND ABLE TO HELP IN TIME OF AN EMERGENCY IF AVAILABLE?  __________

Thank you for taking the time to fill out this form.  By having this information available, our Emergency Committee can be prepared to assist people who do not have alternate heat, ie. wood stoves or furnace available.  We hope we will not have such an emergency.  However, should one occur, we want to be prepared.

                                                                        Emergency Preparedness