VIENNA POLICE DEPARTMENT
AND
VIENNA VOLUNTEER FIRE DEPARTMENT
INCLEMENT WEATHER CITIZEN CONTACT FORM
NAME:___________________________________________________________
ADDRESS:________________________________________________________
TELEPHONE:(HOME)__________________(WORK)_____________________
MEDICATION(S):__________________________________________________
MEDICAL CONDITION:_________________________________________ ( ie. dialysis/heart condition etc.)EMERGENCY CONTACTS:
- NAME:________________________________ RELATIONSHIP:________________
ADDRESS:_______________________________________________________________
TELEPHONE:(HOME)_____________________(WORK)_____________________
- NAME:__________________________ RELATIONSHIP:_______________
ADDRESS: ______________________________________________________________
TELEPHONE: (HOME)____________________(WORK)_______________________
I understand that participation in this program is purely voluntary. I am aware of the nature of the service being provided and desire to participate. I release and agree to hold harmless the Town of Vienna, Vienna Volunteer Fire Department, its employees or volunteers from all liability for the consequences of their release of, or failure to release the data provided by me.
SIGNATURE:______________________ DATE:____________________
RETURN OR MAIL TO: Chief of Police - Town of Vienna
215 Center St., S.
Vienna, VA 22180-5731
