Facility Name

Website/URL:

Address:

City:

State:

Zip Code:

County:

Geographical Location

Phone:

Facility FAX:

Facility Type:

Parking Spaces:

Male Restrooms:

Female Restrooms:

Number of Showers:

Are You in a Flood Plain?

Are you sanctioned or do you have an agreement with the American Red Cross to be a disaster shelter?

If you are a designated shelter, can you serve as a special needs shelter?

Have you previously provided any type of service for emergency situations within your community?
Please explain.

Are your facilities equipped to be an emergency command post for emergency services?

Are your facilities equipped to be a regional or local distribution center for supplies in emergency situations?

Are you invited to your local EOC meetings?

What is the name of the closest EOC administration that you deal with in your local area?
If unknown, type N/A.

During an emergency, what organization currently deals with the usage of your facility for community relief, shelter and/or services?

What direction would you like FFMA to provide you with to facilitate the emergency planning and operations of your facility?

Special Evacuation Directions/Instructions