Dennis Township, Cape May County, New Jersey - Senior Citizen & Handicapped Persons Disaster Information Collection Form

Dennis Township, Cape May County, New Jersey - Senior Citizen & Handicapped Persons Disaster Information Collection Form

December 2006 - Then Mayor Ruth Blessing announced a program of collecting data on Senior Citizens and handicapped persons and has implemented this program in the Township. This program will give our Emergency Management co-coordinator data on all Senior citizens and handicapped residents living in the Township to assure their safety in case of a hurricane or unforeseen disaster in this area. A list will be compiled from all information received by the Director of the Senior Citizen Center. A copy of this list will be kept on file in Township Hall, Emergency Management Office and the Dennis Township Senior Center.
THERE IS NO CHARGE FOR THIS SERVICE

Fill out the form below and click "SUBMIT" when finished.

- Name (Required)
- Address 1: (Required)
- Address 2: (Optional)
- City (Required)
- State (Required)
- ZIP/Postal Code (Required)
- Home Phone (Required)
- Cell Phone (Optional)
- Email Address (Optional)

Special Needs - Please check all that apply

Wheel Chair
Oxygen
Bed-Ridden
Blind
Language Barrier

Other pertinent information:

Please hit SUBMIT to e-mail this form.

Thank you for filling out this form and submitting it to the Director of the Senior Citizen Center and our Emergency Management Co-ordinator.

Email: Main Office or Information

571 Petersburg Road, Dennisville, N.J. 08214, Phone: 609-861-9700

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