Emergency Management Cell Phone

CARE PROVIDER EMERGENCY INFORMATION STATEMENT

**** - ****

Name: Date: I have received a copy of Coastal Concierge Services Comprehensive Emergency Management Plan. In the event of an impending disaster or Hurricane I will:

Be staying in the local area.

Be leaving the local area and going to the following location.

I may be willing to assist Coastal Concierge Services with the following:

Stay with a client in their own home if needed.

Travel with a client outside of the disaster area if needed.

Assist with transportation of clients as requested.

Accompany and assist a client at a regular Red Cross shelter.

Accompany and assist a client at the Special Needs shelter.

Other:

I am unable to assist with client care.

My preferred method of contact during an emergency is: o Cell phone call or text Cell phone number: o Email Email address: Please provide us with an alternate contact name and phone number in case we cannot reach you during an emergency.

ALTERNATE CONTACT NAME:

ALTERNATE PHONE NUMBER:

Rev. 2/2023 KM