Eaton’s Neck Emergency Information Form

POENB and The Eaton’s Neck Fire Department URGE ALL residents to fill this form out so that in the event of an emergency the Fire Department and Police will able to better assist our community.

Please fill this form out and leave it in the POENB BOX at 65 Eatons Neck Road

Name:______________________ Address:____________________________

Total No. of People at location:_____ No. of Children under 2:___

Please List Name of Everyone Living at Location:_____________________________

_________________________________________________________________

Phone:_________________ Cell Phone:___________________

Pets:____________________________________________________

Anyone with special medical needs including medication needs, oxygen, etc.: Yes/No

(If yes please explain)_____________________________________________________________

_______________________________________________________________________________

In case of emergency phone number (someone off of Eatons Neck)_________________________

Next of Kind: Name/Address/Phone:_________________________________________________

Do you have medical training Yes/No: (If yes please explain)_____________________________

Are you interested in participating in assisting implementation of emergency plan: Yes/No

Do you have any of the following (Please check all that apply):

Generator ___ Chain Saw ___ Heavy Pick-Up Truck ___

Boat ___ Propane Tank Large ___ Portable Propane Tanks ____

Portable Cooker ___ Fireplace ____ Camping Equipment _____

Bobcat/Tractor ___