West County EMS and Fire Protection District - St Louis County, Missouri - West County Information Collection Service

West County Information Collection Service

Family Last Name *
Your First Name *
Number of people in your household *
Their ages *
Street Address *
Zip code *
Telephone Number *		Numbers only, no dashes
Cell phone Number *
Would you permit us to send a text message over your phone, if we needed to disseminate information in an emergency *	Yes No

Email address
Would you permit us to email you? [w/ district or public safety information] [w/ emergency information only]	Yes No
Do you have transportation?
Do you have pets that will require evacuation? How many?
Do you and your family have alternate shelter identified in your emergency plan?
Will you require assistance finding shelter?
Do you plan to board your pets, should an evacuation become necessary? If so, where?
Does any member of your household have any special needs? Please describe:
Would they require assistance if an evacuation were to be ordered?
What languages are you or your family able to read, write and understand
Do you or other members of your household have any resources to offer in a disaster? Examples may include, ham radio operation, transportation for neighbors, medical knowledge, etc…
Are you or other members of your household trained as Community Emergency Responder Team members? (CERT)
Fill in the Black Letters Only

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Administration - 223 Henry Ave
636-256-2000