Emergency Response Card
Your name:
Physical address:
Your daytime number:
Emergency Contact
outside the home &
Phone Number:
Emergency Contact
outside the home
address:
IF SPECIAL NEEDS INDIVIDUALS RESIDE IN YOUR HOME, PLEASE CHECK THE
APPROPRIATE CATEGORY
TO DESCRIBE THE SPECIAL NEEDS.
Hearing Impaired                     Speech Impaired                   
  

Mentally Impaired                     Wheelchair/Bed Confined    
      

Visually Impaired                      No Special Needs


Emergency Response Card Program

•        Do you live by yourself?

•        Do you have ones at home that may not be able to contact the Fire     
     Department in case of an emergency?

•        Would you like peace of mind knowing that your family or important others will
be contacted should anything happen to you or your property?

If you've answered yes to any of the above questions, please consider enrolling in
the Emergency Information Response Card Program.  This program is available to
all residents of all ages and offers secure and confidential storage of emergency
contact information and information on any special needs you may have in case of
an emergency at your home.

Recent computer updates at the Vermillion County Dispatch can provide the Clinton
Township Fire Department with immediate access to residents emergency
information when 9-1-1 is called.  The vital information you supply today could help
save a life tomorrow.

We encourage all residents to participate! The process is simple. Just complete the
Emergency Response page below and automatically send it (with an internet
connection and locally installed e-mail program) or mail it back to the Clinton
Township Fire Department.  When the department receives this information, it will be
entered into the database and be available for emergencies.  That's It!  No need to
reapply.  Once you are enrolled in the program, you will be contacted by the Fire
Department once a year to verify that the information on file is still current.  If any of
your information does change before you are contacted, just call the Fire
Department with the update.

Should you have any additional questions or wish to update the form, please
contact either Chief Ryan Akers, or Asst Chief, Scott VanBuskirk at 765-832-1686.

You can print out the form and mail it to:  Clinton Township Fire Department  501 W.
Washington Street Clinton, IN. 47842
Or Fax the form to 765-832-6258.