The Episcopal Church of the Good Shepherd
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The Church of The Good Shepherd  -  Family Emergency Information - 2008
 
As part of Good Shepherd’s Hurricane Preparedness Plan we want to be certain that all of our Parish family can be contacted and assisted, if needed, before, during and after a hurricane or flooding storm.  Please fill out both sides of this form and place in the box in the church Narthex or office or you may return by mail to: The Church of the Good Shepherd - 400 Seabrook Rd., Tequesta, FL 33469.
 
Please Print
 
Head(s) of Household:
            First Name:   _________________________________  Last Name:  ____________________________     
 
            First Name:   _________________________________  Last Name:  ____________________________     
 
Address:  _______________________________________________________City/Zip ___________________
 
Home Phone: __________________  Cell Phone: ___________________ Email:  _______________________
 
Please list the names of all others who live at this address.
 
Name:  ________________________________________________________  Child         Youth              Adult  
 
Name:  ________________________________________________________  Child         Youth              Adult     
 
(if more space is needed, please use the reverse side for others in your household.)
 
1.  Evacuation Level of your residence (circle):         Evacuation      Non-Evacuation          Not Sure
 
2.  Residence Type:                 Single Family Home               Apartment/Condo                   Mobile Home
 
3.  In case of evacuation do you require special assistance with transportation to a shelter?    Yes      No
 
4.  In the event you are forced to evacuate, you and your family intend to:
 
   ____ haven’t made plans
 
   ____ leave the city - to go where: ______________________________________ Phone: ________________
           
   ____ stay with these nearby relatives/friends:  ____________________________  Phone:  _______________
 
   ____ go to a motel/hotel in:   ________________________________________________________________
 
   ____ go to a Red Cross Shelter.  Location:  _____________________________________________________
 
   ____ I am pre-registered * at the following Special Needs Shelter: ___________________________________
 
Text Box:      Emergency contact person in case we are unable to locate you at any time or during any emergency.      Local /family or neighbor name:  ____________________________________  Phone:  ______________   
     *   If you do have special needs and haven’t pre-registered, do you need contact information:  Yes      No