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Disaster Assistance Information Form

  1. Type of Assistance Required*

  2. Evacuation Transportation Necessity*

  3. List your emergency contacts below.

  4. I hereby authorize Roscommon County Central dispatch to release all or part of such information as may be necessary to ensure my safety, treatment, and well being in the event of a medical disaster or public emergency.

  5. Leave This Blank:

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