ARC Safe and Well Registration HTML  Vers 1.1                                              
ARC Instructions for using Form
Use this form when there is no internet connectivity available and someone wishes to register on the Safe and Well website. Forms should be taken to the nearest location for data entry into the Safe and Well website. Treat the form as confidential information and shred it following data entry.
CLIENT INFORMATION
First Name If Registering as A A./N Organization): 
    		LAST NAME (or Organization) :  
 
EMAIL ADDRESS (suggested):    DATE of BIRTH (suggested) :       
PREDISASTER HOME INFORMATION
PRIMARY PHONE
WORK PHONE (SUGGESTED) OTHER PHONE (SUGGESTED) :  
HOME ADDRESS:         CITY:       STATE:  
 ZIP:  
 
BEST CURRENT CONTACT INFORMATION
HOME ADDRESS:         CITY:       STATE:  

 ZIP:  
 
SAFE AND WELL MESSAGES
(check boxes next to appropriate messages to make your selctions)

I am safe and well
Family and I are safe and well
Currently at shelter
Currently at home
Currently at family member/friends house
Currently at a hotel
I am safe and in the process of evacuting

I am evacuating to a shelter
I am evacuating to the house of a family member/friend
I have evacuated and I am safe
I am currently/remaining at home
Will make phone calls when able
Will email when able
Will mail letter/postcard when able

CUSTOM MESSAGE
You may add your own custom short message, up to 255 characters. Please take care that your message is appropriate for the public, and do not unclude names or details if doing so could be harmful to you or others.

FOR ARC Use Only
Date and time entered: DRO Number / Location: Name or Enter DSHR number:

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