Do You Require Evacuation Assistance In An Emergency?

In addition to the traditional annual calendar emergency assistance card, New Hampshire Homeland Security and Emergency Management (NH HSEM) is now offering the option to submit or change the same information online at any time. NH HSEM utilizes this information to properly assist and evacuate individuals with disabilities, access, and functional needs in the area of the Seabrook Station Nuclear Power Plant in the event of an emergency. Even if you have submitted your information, we ask residents to submit their information each year.

THIS INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL FOR STATE AND LOCAL EMERGENCY USES ONLY.

Please read each option carefully so we can record the information to the best of our ability.

Are you a local or state official submitting an entry or revision on behalf of a resident with access and/or functional needs?*
- Yes
- No
Community*
Your name:*
First Last
Fill out the rest of this form on behalf of the resident.
Would you like to be added, removed, or provide your updated your information?
Optional
Please provide the reason for removal:
Please check each box that applies to your assistance needs:
- Communication
- Vision
- Mobility
- Medical
- Supervision
- Assistance will be needed out of home
I require special transportation by:
- Bus
- Wheelchair Accessible Vehicle
- Ambulance
Residence type
- House
- Apartment
- Assisted living
Do you have a service animal?
- Yes
- No
Please include the type of animal, weight, and any other information you'd like to provide.
Contact Information
Name
First Last
Which community within the Seabrook Station Emergency Planning Zone do you reside in?*
Is your physical address the same as your mailing address?*
- Yes
- No
Home Address*
Street Address Address Line 2 ZIP Code
Mailing Address*
Street Address Address Line 2 City ZIP Code
Primary Phone
Secondary Phone
Email
Confirm Email*
Would you like to include contact information of a relative/person you would like us to notify to assist you in an emergency?*
- Yes
- No
Name of relative/person we can notify to assist you in an emergency*
First Last
Relationship
Primary Phone
Secondary Phone
Home Address*
Street Address Address Line 2 City State ZIP Code
Other information or comments:

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Do You Require Evacuation Assistance In An Emergency?

THIS INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL FOR STATE AND LOCAL EMERGENCY USES ONLY.

Fill out the rest of this form on behalf of the resident.

Contact Information