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Voluntary Emergency Registry

  1. This form will provide City of La Vista Police and Fire Personnel with important information in order to be able to respond to your needs in the event of an emergency.

    If you are unable to read or submit this form online, please participate by contacting us via email at or telephone 402-331-1582

  2. Your information will be kept in strict confidence
  3. Sex*

  4. Are You (please select any condition that you wish to notify us of)
  5. Do you use a:
  6. If wheelchair, is it
  7. Are you
  8. Other mechanical necessities

  9. Leave This Blank:

  10. This field is not part of the form submission.