Safe Room Registration Form

Safe Room Registration Form
Fill out the form carefully for registration
CITY OF CHICKASHA RESIDENTS ONLY
This Safe Room Registration Form is provided as a way for residents to inform the Chickasha Emergency Management Agency where their safe room or shelter is located. This information will be listed in a database that will be used in the event of a disaster to help the City determine where people may be trapped.The information is kept confidential and will not be shared with individuals, companies or other agencies.
It is very important that you enter the information correctly. Please review the information before you press the submit button. ALL BLANKS SHOULD BE COMPLETED. (IF YOU HAVE PROBLEMS SUBMITTING THE FORM, PLEASE CONTACT THE EMERGENCY MANAGEMENT OFFICE AT 405-222-6000)
(If you have a COUNTY STREET or ROAD address you are located outside the City Limits of Chickasha and you are not eligible for this Registration and your information will not be saved.)
Name*
First NameLast Name
Shelter Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
E-mail
Phone Number
Area CodePhone Number
Average number of people that will use the shelter:
Location and Description of the Shelter on the property (Be Specific):
Shelter Type:
Under GroundAbove Ground
Material:
ConcreteSteel
Shelter Door is Located:
Outside ALL BuildingsInside a Building
Additional Comments
During the processing of this information, Staff will visit the property to obtain a Global Positioning System (GPS) reading so the property may be located if all of the landmarks are been destroyed during a disaster. Staff will not need access to your property or the shelter during this process.
Should be Empty: