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Amherst CERT - Special Assistance Registration Form

  1. Amherst_CERT.png

  2. Recieve Text (SMS) Messages?

  3. 1.) Have a physical or disability or mibility problem that would interfere with evacuating your home or going to an Emergency Services Facility?

  4. 2.) Take medication for diabetes?

  5. 3.) Have a chronic medical condition that requires medication?

  6. 4.) Take a medication that if you ran out of that medicine it would be terminal?

  7. 5.) Have a compromised immune system?

  8. 6.) Require supplemental oxygen?

  9. 7.) Have a severe hearing or vision problem?

  10. Leave This Blank:

  11. This field is not part of the form submission.