The Corporation of the Municipality of Red Lake

Emergency Registration Form

The Corporation of The Municipality of Red Lake invites residents who require special assistance to participate in providing valuable information to the Municipality in the event of a Community Emergency. In particular, those that are most vulnerable in an emergency situation: the elderly, disabled, those with special medical requirements, live alone, have no local support network or means of transportation, etc. should complete an Emergency Registration Form.

The Clerk’s Office maintains a listing of the Emergency Registration Forms. If you completed an Emergency Registration Form last year, you are not required to complete another one, unless your information requires an update.

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Please Leave Alone
Also Please Leave Alone

General Registrant Information

Last Name:
First Name:
Civic Address:
Unit or Apartment Number:
Town:
Telephone:
Mobile Phone:
Emergency Contact Person Full Name:
Emergency Contact Person Phone Number:
Emergency Contact Person Mobile Number:
Location of Common Entrance to House:
If other please specify:

Special Assistance Information

Please check all that apply

Vision Impairment:
- Total Vision Loss
- Partial Vision Loss
Hearing Impairment:
- Total Hearing Loss
- Partial Hearing Loss
Mobility Impairment:
- Total Immobility
- Partial Immobility
- Wheelchair Available at your residence
- Stair Lift Available at your residence
- Elevator Access at your residence
- Ramp at your residence
Intellectual Disability:
Chronic Medical Condition(s):
- List Conditions seperated by a comma(,):
Mental Health:
Other:
If other please specify
Difficulty with Speech or Language:
Please Specify

Life Sustaining Equipment Information

Please check all that apply

Ventilator:
Oxygen:
Dialysis:
Other Equipment:
If other please specify
Require Electricity for life sustaining equipment:
Hours until electricity is required to remain safe:

Other Important Information

Please check all that apply

Live Alone:
No Local Support Network:
No Transportation:
No One to provide transportation:

Review and Submit

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