Vulnerable Citizens Registry

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Date: *

Name *

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Last

Address *

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Phone Number (Landline) *

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Number in Household *

Children in household *

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If so, what ages? *

Do you have transportation? *

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Nearest Relative (Name) *

Their address: *

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Special needs: *

Referred to: *

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PLEASE RETURN TO: WILLIAMSON COUNTY EMERGENCY MANAGEMENT AGENCY
407 N MONROE ST, SUITE 370, MARION, ILLINOIS 62959