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Town of Sudbury → Committees → Local Emergency Planning Committee

Sudbury Voluntary Registry

In the event of an emergency in Sudbury, you may need to care for yourself for up to 72 hours, even if the electric power fails. The Town is making plans to help its residents in case of a serious emergency, but it is important for everyone to be prepared to help themselves.

Some people may need or want special help planning for themselves, or might need special assistance if they should have to be evacuated to a shelter. It will help our “first responders” (police and fire personnel, the Citizens’ Emergency Response Team and the Medical Reserve Corp) to be aware of the location and needs of people with these special circumstances.

If you are such a person (or are the caregiver for one), you can join a voluntary registry that will help local authorities be aware of your special needs. This information will be kept confidential to the extent required by law. The Sudbury Public Health Nurse will call you to provide additional planning assistance.

Please fill out the Sudbury Voluntary Registry form below and then submit. If you would like to print your application, print the completed form before you submit the application. You must answer the last question about the name of the town with Sudbury; otherwise, the form will not be submitted. This is to prevent bots from sending spam via this form. Thank you for your input!

PARTICIPANT INFORMATION

If you would need special help in an emergency, you may wish to fill out and return this form so that you can receive assistance developing an action plan for your personal safety.* This information will be kept confidential by local authorities to the extent required by law. The Sudbury Public Health nurse will call you to provide additional planning assistance.

Name:

Date:

Address:

Date of Birth: (Optional)

Telephone:

Cell Phone:

I am prepared to care for myself for 72 hours in case of emergency that may include electric power failure.

(No choice selected.)
Yes
No

Special circumstances that affect my emergency planning or that may affect my ability to be evacuated to an emergency shelter include:

I do not have transportation available to leave the area in an emergency.
I need transportation help but I can ride in a van.
I am in a wheelchair and would need a wheelchair van.*
I would need to ride in an ambulance.*
I have specialized medical equipment and require special transportation.*
I am hearing impaired.
I am vision impaired and need special help.
I use oxygen.
I have a service animal.

Other Special Circumstances:

(Response character length limit: ; remaining: )

I acknowledge that I am providing this information voluntarily.

(No choice selected.)
Yes
No

I agree to allow my information to be shared with the Sudbury Commission on Disability.

(No choice selected.)
Yes
No

*Please be aware that the Sudbury Fire department and other Town departments are committed to providing assistance in emergencies, but depending on the nature of the emergency and its duration it may not be possible to provide immediate assistance with evacuation. For this reason it is important that all citizens make plans and preparations to care for themselves.

Please answer the following question before sending your responses.

What is the name of this town? (7 letters)