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Home
Flooding
Flood Protection Information
About Appleby Floods
What AERG Do
Emergency Plan
Emergency Contacts
Homes and Businesses
Priority Services
what3words
History of Flooding & Gallery
River Levels / Flood Hub / Useful Links
Appleby Emergency Support Network
Registration Form
Pandemic
Coronovirus Response
Getting Help / Useful Links
Mental Health
What We Did / Gallery
About Us
About Us
Policies
Funding
Funding Highlights
Committee Member Login
Volunteering
Volunteer Roles
Volunteer Registration
Volunteer Login
Latest News
Events
Contact us
Privacy Policy
Home
Flooding
Flood Protection Information
About Appleby Floods
What AERG Do
Emergency Plan
Emergency Contacts
Homes and Businesses
Priority Services
what3words
History of Flooding & Gallery
River Levels / Flood Hub / Useful Links
Appleby Emergency Support Network
Registration Form
Pandemic
Coronovirus Response
Getting Help / Useful Links
Mental Health
What We Did / Gallery
About Us
About Us
Policies
Funding
Funding Highlights
Committee Member Login
Volunteering
Volunteer Roles
Volunteer Registration
Volunteer Login
Latest News
Events
Contact us
Privacy Policy
Search for:
Registration Form
info@applebyerg.co.uk
2022-09-01T15:04:20+00:00
Appleby Emergency Support Network
RM_Stats
Household Registration Form
Name of main householder:
*
Mobile number:
Landline number:
Email address
*
Full address
Address Line 1
Address Line 2
City
State or Region
Zip
Total number of occupants:
Number of occupants under age 5 or elderly / vulnerable:
Your Nominated Emergency Contact
This should be the person that you would want us to contact on your behalf if required
Name:
Contact number:
Vulnerable / elderly person?
Yes
No
If yes, please give more details:
Emergency Communication
Please select the types of emergencies you would like to be kept informed about:
Flooding
Emergency Town Bridge Closure
Pandemic event
Utilities failure (water / gas / electricity)
Severe storms & gales
Severe cold & snow
Telecommunications outage (mobile / broadband / landline network)
Severe drought / heatwave
Major incident causing significant disruption
Details of vulnerability
Please tick all that apply
Age related (pensionable age or children under 5 in property)
Chronic / serious illness
Communication difficulties (impaired hearing, speech, vision)
Medical dependant (medical equipment, support equipment, stairlift etc)
Poor mobility
Other (please detail):
Other information
Please detail any other useful information such as disabilities, any pets in the household etc.
I understand that this information will be kept by Appleby Emergency Response Group, solely for its own purposes, but some details may be passed to the emergency services during an emergency situation. These details can be destroyed at any time upon request. Please visit www.applebyerg.co.uk/policies to view our data protection policy, or request a copy by phoning 07467 589238.
I Agree
Date:
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