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Disaster and Emergency Form
Name of Family: _________________________________________________________
Address: ________________________________________________________________
Home Telephone #: ____________________ Mobile Telephone #: _________________
E-mail Address: ____________________________________@ ____________________
Family Link has developed this document to ensure that foster/adoptive families have a
plan for and can be located in the event of an emergency or disaster (natural or
otherwise), have information on disaster preparedness, and understand Family Link’s
disaster policy. Please answer the following questions so that you can be found in the
event of an emergency. Please notify Family Link’s Emergency Number if there are any
changes to this plan.
EMERGENCY CONTACTS
Please designate two people that do not live with you will call to tell them of your location and contact
information in the event you must evacuate your home. If you cannot be located after an emergency,
Family Link will contact them.
Contact #1
Contact #2
Name
Name
Address (Street, City, State, ZIP)
Address (Street, City State, ZIP)
Home Phone Number
Home Phone Number
Mobile/Secondary Phone Number
Mobile/Secondary Phone Number
FAMILY LINK DISASTER POLICY
You are required to evacuate if an evacuation is mandated (required) for the area in
which you live. Once you reach your evacuation destination, you are required to contact
Family Link as soon as possible. If the Family Link office is closed, you may call the
Emergency Number (512-945-8953) to make the required notification. If Family Link
cannot reach you following an evacuation, we will contact the emergency contacts listed
on this form.
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When evacuating, you should take, at minimum, the following items: at least a 2-week
supply of medication in its bottle (if applicable), other medical supplies and equipment
(such as a first aid kit, glasses, etc.), important papers (such as Placement and Medical
Authorizations, Medicaid Card, Medical Binder and Educational Portfolios for each
child), this Disaster and Emergency Form, and contact information for the children’s
Case Worker and their Supervisor. The phone number 2-1-1 can be called to find out
information about shelters and disaster –related services.
OUR PLAN FOR DISASTERS THAT OCCUR WITHOUT WARNING
1. In the event an emergency occurs without warning that prevents us from returning
to our home (for example fire, flash flooding, act of terrorism), we plan to (choose
one):
_____ Stay with family/friends
Name(s) _____________________________________________________
Address _____________________________________________________
Phone Number _______________________________________________
_____ Stay in a Hotel
_____ Other (describe) ______________________________________________
2. What is your alternate plan?
Describe __________________________________________________________
OUR PLAN FOR DISASTERS THAT OCCUR WITH WARNING
1. In the event there is a warning that a potential disaster such as a hurricane or
tornado could head toward our residence, but officials DO NOT mandate
(require) that people evacuate, we plan to (check one):
_____ Stay with family/friends
Name(s) _____________________________________________________
Address _____________________________________________________
Phone Number _______________________________________________
_____ Stay in the Residence
_____ Stay in a Hotel
_____ Stay in a Shelter
_____ Other (describe) ______________________________________________
2. What is your alternate plan?
Describe __________________________________________________________
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3. If an evacuation for our area were mandated (required), we would go (check one):
_____ Stay with family/friends
Name(s) __________________________________________________________
Address __________________________________________________________
Phone Number _____________________________________________________
_____ Stay in a Hotel
_____ Stay in a Shelter
_____ Other (describe) ______________________________________________
4. Who would provide transportation for you to evacuate? Check one.
_____ Self
_____Other (Name and phone number) _________________________________
5. Is there anyone in your home who would require special attention during an
evacuation? Check One.
_____ Yes.
Name(s) __________________________________________________________
Type of attention needed: ____________________________________________
_____ No
NOTE: YOU MUST EVACUATE IF IT IS MANDATED IN YOUR AREA.
BASIC DISASTER PREPARATION INFORMATION
Examples of disasters are vast and can include anything including a single house fire or a
hurricane that destroys cities. They can occur with little to no warning and can occur at
any time of the year, so it is important for everyone to be prepared at all times. Everyone
should have enough emergency supplies to last for at least one week. This would include
non-perishable and canned foods, water, medication, first aid supplies, batteries,
flashlights, diapers (if applicable), and a battery-powered radio. It is also recommended
you have information on local emergency services (addresses and phone numbers)
written down in a secure place. If you must evacuate your home, make sure you have all
necessary contact information and supplies which will be needed while you are gone.
Evacuations can last less than a day or for an undetermined period of time. More
information on preparing for a disaster can be located online at the Red Cross’ disaster
preparedness website, www.prepare.org.
FOSTER PARENT SIGNATURES
___________________________________ ___________________________________
Signature/Date
Signature/Date
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