Required fields are marked with asterisks (*)

Person(s) Requiring Assistance

The Township of Scugog Fire Department maintains a database of individuals with disabilities or special needs, who might require special assistance in the event of a fire or other emergency. This allows us to be aware of your needs and serve you better. If you would like to have yourself or a loved one added to this database, please provide the following information:

Name of Person Requiring Assistance:

Address of Person Requiring Assistance:

Name of Primary Contact (if different from above):

Phone number of Person Requiring Assistance or Primary Contact:

Email Address of Person Requiring Assistance or Primary Contact:

Please note that email is our preferred method of contact to complete annual reviews to determine if the information on file remains the same. If an email address is provided, it will not be used for any purpose other than to keep the database up to date.

Details of Condition:

Assistive Devices (please list):

Visual Issues

Oxygen in home

Hearing Issues

Cognitive Issues

Mobility Issues

Additional Information (ex. Dementia, Alzheimer's, Guide Dog, Anxiety Disorder, is Blind or uses Hearing Aids):

I certify that the above information is correct.

Yes