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Emergency Services Disability Indicator Form

This form is utilized to assist emergency personnel within London's city limits in responding to an emergency at your address.

Name *

First

Last

Phone Number *

Address *

Access Information

Please provide any special code or access information to make entry on/in property.

Please check all that apply to indicate that someone at the address:

LSS Life Support System: has equipment required to sustain their life
MI Mobility Impaired: is bedridden, wheelchair user or has another mobility impairment
B Blind: is legally blind
DHH Deaf or Hard of Hearing: is deaf or hard of hearing
TTY Communication via the phone may be TTY
SI Speech Impaired: has a speech impairment
CI Cognitively Impaired: is cognitively impaired
ASD Autism Spectrum Disorder

Please fill this form out again if the status of the above disability indicator(s) change at any time.

Location of Person in Need

Is there a place where an individual is located, for example, a specific room or floor of the home?

How Many Reside at the Residence *

Are You Interested in Additional Fire Department Programs?

Please check all that apply.

Confirm Email

Message

(606) 864-2922
London Fire Station