Fair Lawn Office of Emergency Management

8-01 Fair Lawn Avenue

Fair Lawn, New Jersey  07410

201-794-5390     201-791-0175  (fax)

oem@fairlawn.org

 

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RESIDENTIAL SPECIAL NEEDS ASSISTANCE FORM

Dear Resident,

The Borough of Fair Lawn Office of Emergency Management has established a Residential Special Needs Registry for citizens who may require special attention during times of emergency.  If you or someone you know is using oxygen in their home, requires a walker to get around, is on kidney dialysis, or has any other form of physical or mental disability, please take a few moments to fill out this application.  

If you want to print out the form to drop off, mail, or fax, click here.   You can also fill out the form below and submit it to our office electronically.

Please be assured that all information is kept confidential and is distributed to the police, fire, rescue, ambulance, health, and public works departments for use during emergency.

If you have any questions, please feel free to contact the Office of Emergency Management at the above listed telephone number.

NAME:      

ADDRESS:     

PHONE #:   

CELL PHONE #:   

E-MAIL:     

TYPE OF DISABILITY:     

DO YOU NEED ELECTRIC POWER TO OPERATE MEDICAL EQUIPMENT?  Yes    No

DO YOU HAVE A BACK-UP GENERATOR THAT WILL ACTIVATE UPON LOSS OF POWER?  Yes    No

EMERGENCY CONTACT NAME:     

RELATIONSHIP TO ABOVE PERSON: 

EMERGENCY CONTACT ADDRESS:     

EMERGENCY CONTACT PHONE # (HOME):          

EMERGENCY CONTACT PHONE # (CELL):        

EMERGENCY CONTACT PHONE # (WORK):        

EMERGENCY CONTACT E-MAIL:      

DOES A FAMILY MEMBER OR NEIGHBOR HAVE A KEY TO YOUR RESIDENCE IN CASE OF AN EMERGENCY?

IF YES, PLEASE COMPLETE:

NAME:     

ADDRESS:     

PHONE # (HOME):          

PHONE # (CELL):        

PHONE # (WORK):