EMERGENCY RESPONSE DATA FORM 
Filing of this form is 100% Voluntary and Confidential 
Town of Amherst Office of Emergency Management
Brandon Peters, Director                 Daric Will, Coordinator 
Everybody has needs … Do the right people know what yours are? 
IF you or someone in your household has a disability or a special medical need, the people whose job it is to respond when you call for help in an emergency need to know. Whether it affects your entire community, your street or just your home, seconds can make a life-or-death difference. That's why we encourage you to take a minute to fill out this form and return it to the address provided below.  Having specific details about your special situation will significantly help us to help you.  For more information contact (716) 631-7122. 
Last Name ___________________________________ First Name __________________________ Date _______________
Street Address ______________________________________________________________________ Apt. No. __________
Town / State / Zip _____________________________________________________________________________________
Type of Residence (please check one):
 _______ Single Family Home       _______ Assisted Living Facility       _______ Senior Housing Complex / Facility
Phone # _________________________________________            How many live in the household? ___________
Age _________ Date of Birth ________________________ Your language, if not English ____________________________
Emergency contact for the above-listed resident: 
Name ______________________________________________ Relationship to resident ____________________________

(circle one) 		 (circle one) 	
yes 	no 	Are you confined to your bed? 	Are you on constant oxygen? 	yes 	no 	
yes 	no 	Are you on dialysis? 	Are you visually impaired? 	yes 	no 	
yes 	no 	Are you hard of hearing or deaf? 	Are you on life support? 	yes 	no 	
yes 	no 	Do you live alone? 	Do you have your own transportation? 	yes 	no 	
yes 	no 	Do you use a wheelchair? 	Do you have a service animal? 	yes 	no 	
yes 	no 	Can you walk with assistance? 	Do you have mental health concerns? 	yes 	no 	
yes 	no 	Do you have an intellectual disability? 	Please return this form to:			
		Please describe:_________________________ 	Town of Amherst			
		  ______________________________________ 	Dept. of Emergency Management			
		  ______________________________________ 	4220 Bailey Ave, Amherst, NY 14226			

Primary phone # ____________________________________ Secondary phone # _________________________________
This form can also be found online at www.amherst.ny.us. Use Keyword NEEDS.