Storm Shelter Registration

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Work Phone Number *

Type of Shelter *

Type of Shelter Comments *

Any children stay at home alone? *

Yes No

If yes, please include the name and age of each child below.

Name *

Age *

Name *

Age *

Name *

Age *

Name *

Age *

Emergency Contact *

Phone Number *

GPS Location *

Emergency Contact *

Phone Number *

Exact directions to home from Bridge Creek Fire Station #1 *

Exact location of cellar/safe room from the driveway of home *

By signing below, I understand by registering my cellar/safe room with the Bridge Creek Fire Department, that my cellar/safe room will be checked for entrapment by debris, after a tornado. I understand that my cellar/safe room will be checked as quickly as manpower is available to perform such search and rescue. I further understand that it may be several hours, depending on the size of the emergency, before I can be rescued from my cellar/safe room. I understand that I need to keep my cellar/safe room stocked with survival supplies and have been given a suggestion list by the registrar. With my signature, I release the Bridge Creek Fire Department and Bridge Creek Fire Protection District from any liability, for any event that occurs due to delayed rescue.

E-Signature *

Date *

Submit

Storm Shelter Printable Registration Form
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File Type:	doc

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