2. 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 LVPD@cityoflavista.org or telephone 402-331-1582
4. Your information will be kept in strict confidence
6. Date*
8. Name*
9. Address*
11. City*
12. State
13. Zip*
15. Age
16. Height
17. Weight
18. Sex*

    1. Male
    2. Female
20. 
    
22. Are You (please select any condition that you wish to notify us of)

    1. Ambulatory
    2. Non-Ambulatory
    3. Bed Bound
24. Do you use a:

    1. Walker
    2. Cane
    3. Crutches
    4. Wheelchair
26. If wheelchair, is it

    1. Manual
    2. Motorized
28. Are you

    1. Sight Impaired
    2. Hearing Impaired
30. Other (please specify)
32. Other mechanical necessities

    1. Ventilator
    2. Oxygen
34. Other (please specify)
36. 
    
38. Caretaker or physician to contact in an emergency*
40. Phone*
41. Relationship to you*
43. 
    
45. Other Information
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field