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Voluntary Request for Emergency Preparedness Planning Support

If you have a disability or an access and functional need, you may need to take additional steps to prepare for emergencies. Please review the University of Richmond’s information about preparing for emergencies.

After completing this request form, a representative from the Office of Emergency Management will contact you to assist you in developing an Individual Emergency Preparedness Plan.

This form does not replace the University of Richmond Application for Disability Accommodation. This form may only be completed by the individual requiring support.

* Indicates required field.

*Name:

*Affiliation:
Student
Staff
Faculty

*Email:

Campus Residential Address:

Campus Office Address (if applicable):

Campus phone number:

Office phone number:

Functional Need(s) (Optional):
Mobility
Blindness or Visual Impairment
Deafness or Hearing Impairment
Use of a Service Animal
Learning Disability
Communication/Speech Limitation
Psychological
Other

Limitations and information emergency personnel should be aware of (including medication):

I understand that by completing this form my information will be used to aid in emergency planning. I understand I will not receive preferential response or consideration in an emergency or be guaranteed immediate assistance because I have completed this form. I understand that I must update the information provided if it changes.

*Signature:

Date: