Willowbend Disaster/Emergency Info for ______

Willowbend Disaster/Emergency Info for ______(Address)

Date: ______Zone Captain: ______Tel #:______

Name Adult/ Perm./ Rent Special Needs* Child PartTime

* If you will need assistance in an evacuation, please register NOW with the Sarasota County Department of Emergency Management. Pre-registration is mandatory. Call 941-861-5000

Local Emergency Contact with a Key to Your House Out of State Emergency Contact

Do you have an Evacuation Plan (Where you will Storm Need Assistance Putting Willing to Assist meet and find shelter)? Protection? up Storm Protection? Others?

Pets (Note: SHELTERS REQUIRE WRITTEN PROOF OF CURRENT RABIES SHOTS AND VACCINATIONS. PETS MUST BE IN A CAGE OR CARRIER ) Pet Species (e.g., dog, cat) Name Breed Special Needs

It is important for first responders to know the Locations of the following Hazardous Materials in Case of Disaster: Ammo/Guns Gasoline (outside car) Medical Equipment Oil Oxygen Tanks Oxygen Tanks (large) Paint Paint Thinner Pool Chemicals Propane Tank(s) From this List, what are the Hazardous Materials at this Address and what is their Location? Hazardous Material Location Hazardous Material Location Hazardous Material Location

The Following are Equipment that would be useful in Case of Disaster. List any of these that you have and are willing to make available: Air Compressor Axe Blood Pressure Monitor Car Jack-Hydraulic Chain Saw Cordless Saw Crow Bars Fire Extinguisher Generator-Gasoline Generator-Natural Gas Inflatable Bed Inflatable Boat Jet Boat Kayak Ladder (Extension) Ladder (Step >= 6’) Lights Power Cords Power Washer

Knowing which residents have special training will improve our ability to respond to events. Please List: Name Disaster & Emergency Training like CERT, CPR, Date Trained? Interested AED, First Aid, Fire Suppression, Incident in being Command Trained?

Please indicate if you would like to become involved with preparedness activities 

Return this form to your Zone Captain above or to Hugh O’Connor at 1270 Thornapple Drive