Registration Form for the List of Individuals Requiring Special Attention During Emergencies

People living with a disability (physical, visual, hearing or other) or who require special assistance in an emergency situation (fire, evacuation, etc.) are strongly encouraged to register on the list. This allows the Service de la sécurité publique et de la sécurité incendie personnel to plan and adapt their response based on your needs.

Information About the Person With Special Needs

First name•

Last Name•

Date of Birth•

Weight•

Address•

Phone•

Email•

Bedroom location (ex. ground floor, basement, first floor...)•

Information About Your Situation

Select among the following situations:•

Hearing impaired person

Visually impaired person

Reduced mobility

Intellectual disability

Other

Please specify the type of assistance you need.

Information About the Parent or Guardian Responsible for the Person With Special Needs

First Name

Last Name

Address

Phone

I authorize the Service de la sécurité publique et de la sécurité incendie de la Ville de Saint-Lazare to share the personal information provided above with emergency response teams for use and coordination in the event of an emergency. •

I have read and agree to the Privacy Policy regarding the protection of personal information and confidentiality.

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Registration Form for the List of Individuals Requiring Special Attention During Emergencies

This form uses the reCAPTCHA functionality to submit your request.

Information About the Person With Special Needs

Information About Your Situation

Information About the Parent or Guardian Responsible for the Person With Special Needs