911 Form for Individuals with Disabilities

Return to Rockbridge DSB, P.O. Box 774, Lexington, VA 24450.   PLEASE PRINT!!
Check One:     [ ] Residential     [ ] Business     Business name:_________________
Individual's name:____________________________________
Phone: (___) ___-____ # of Occupants: ___
Street Address: ________________________________________________
City, state & zip: _______________________________________________
Mailing address if different from above: ________________________________
  If you have a security system:
Water company: _________________ Alarm code:___________________
Gas company: ___________________ Alarm type: ___________________
Electric company: ________________ Alarm company:________________
Electric meter #: _________________ Alarm co. phone: (___) ___-____
Concise directions to your home: ____________________________________
_____________________________________________________________
Describe your home: (ramps, how many steps, front / back entrance, what floor)________
_____________________________________________________________
Doctor's name: ___________________ Doctor's phone: (___) ___-____
Relative's name: __________________ Relative's phone: (___)___-____
Relative's street address: ___________________________________
City, state & zip: _____________________________________

Medical Concerns:

Please check all that apply:       ___ Blind       ___ Deaf       ___ Speech Impairments       ___ Diabetic

___ Paralysis (stroke, post polio, spinal cord injury, multiple sclerosis, cerebral palsy, muscular distrophy)

___ Use Wheelchair       ___ Amputee       ___ Use Oxygen       ___ Heart Disease       ___ Brain Injury

___ Mental Retardation       ___ Mental Illness       ___ Altzheimer's       ___ Dementia       ___ Service Animal

Please specify ALL disabilities, medications, special equipment, or instructions 911 should be aware of:

___________________________________________________________________________________________