Unless you specify otherwise below, your details will be shown in our
online directory which is only viewable by people who we have
approved and are logged into our website.
Show Email Address(s)
Show Phone Numbers
Please provide us complete information so that we can maintain accurate records.
Omit City, State Zip
Home Phone Number
Work Phone Number
Cell Phone Number
Second Resident's Information
Child 1 Name
Child 1 Birth Date
Child 2 Name
Child 2 Birth Date
Child 3 Name
Child 3 Birth Date
Child 4 Name
Child 4 Birth Date
Additional Household and Emergency Preparedness Information
Additional Household Phone 1
Additional Household Phone 2
Pertinent Family Medical Information
Please include any special needs, and preferred Hospital/Medical Group affiliation (i.e. Kaiser, Stanford, ...)
Two Out of Area Emergency Contacts
To be used to coordinate care and communications in case local lines are unavailable.
Children Contact Information
This information will not appear in directory but may be used to coordinate with your children. Feel free to include cell phone numbers and email addresses.
Household Members with Special Training in Case of Disaster
Please include name and training for each resident as appropriate. Training including but not limited to MD, RN, PA/NP with specialty, EMT, Dentist, Veterinarian, Psychologist, CPR trained, Pharmacist, Law Enforcement, Military, Firefighter, Ham radio operator, plumber,
electrician, contractor, and seismic geologist.
Household Emergency Equipment Relevant for a Disaster
Please include household content including but not limited to generator, ham radio, disaster supplies, shelter, pump, chainsaw, axe, and crowbar.
Where are the Gas, Electrical, and Water Shutoffs
In case of emergency, please provide a brief description of where each of these shutoffs are located, preferably using N, S, E, & W reference points.
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