Home

 Elected Officials Departments and Services

Local Links

Search

E-Mail

City of Berkeley Logo


2100 Martin Luther King Jr. Way, Berkeley, CA 94704
(510) 981-5900, TDD: (510) 981-5799, police@ci.berkeley.ca.us

 
bBox.gif (810 bytes)










Berkeley Police & Fire Department Voluntary Emergency Registry

This form will provide us with important information in order to be able to respond to your needs in an emergency.

If you are unable to read or submit this form online, please participate by contacting us via email police@ci.berkeley.ca.us, or telephone (510) 981-5900.

Date:             

Name:           

Address:      

City:              

Zip Code:     

Telephone:  

E-mail:          

Age:              

Height:         

Weight:         

Sex:               Male Female

                - - - - - - - - - - - - - - - - - - - - - - - -

Please place an "X" next to any condition(s) that you wish to notify us of.

Are you:

  Ambulatory Non-ambulatory
   Bed bound

                 - - - - - - - - - - - - - - - - - - - - - - - -

Do you use a:

  Walker   Wheelchair 
  Cane            - If wheelchair, is it:   Manual
   Crutches    Motorized

                - - - - - - - - - - - - - - - - - - - - - - - -

Are you:

  Sight impaired  
  Hearing Impaired
   Other (please specify)

                - - - - - - - - - - - - - - - - - - - - - - - -

Other mechanical necessities:

  Ventilator
  Oxygen
   Other (please specify)

                - - - - - - - - - - - - - - - - - - - - - - - -

Caretaker or physician to contact in emergency:

Care Taker/
Physician Name:      

Relationship to you:

Phone:                         

Other comments:      

Thank you for submitting this information.