Form Center

2. Please complete this form if you use electricity or battery dependent medical devices and would like to be included on a list of residents needing priority reconnection in an emergency or power outage. If you have questions or would like to provide this information by phone, please call Jhana Wallace, Community Health Coordinator, 781-489-4407.

4. I am completing this form on behalf of (choose one): *

   Please complete a new form for each person in a household who requires assistance. 

   1. Myself
   2. Spouse
   3. Child
   4. Roommate
   5. Other
6. What is your other relation to the person on this form?*
8. First name of person with medical need(s) *
9. Last name of person with medical need(s)*
11. Address*

    Include suite or apartment # if applicable

13. City*
14. State*
15. Zip Code*
17. BEST phone number to reach you during a power outage:*
18. Email
20. Do you have a contact person in case you can't be reached? *

    1. Yes
    2. No
22. Alternative contact person*
24. Alternate contact phone number*
25. Alternate contact email
27. What is the nature of the medical need requiring electricity or battery? Check all that apply*

    1. Dialysis
    2. CPAP/BiPAP Machine
    3. Oxygen
    4. Ventilator/Respirator
    5. Suction Device
    6. Infusions, Intravenous Equipment, Feeding Equipment
    7. Refrigerated Medications That Cannot Be Held at Room Temp
    8. Wheelchair or Electric Scooter
    9. Chair Lift
    10. Other
29. What is Your Other Medical Need? *
31. In an emergency power outage do you need assistance relocating from your home to another location (warming/cooling center, emergency shelter, etc.)*

    1. Yes
    2. No
33. Please share any other information you think we should know:
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field