Emergency Preparedness

5730 Packard Avenue, Suite 100, Marysville, CA 95901

(530) 749-6366 Fax (530) 749-6397

Personal Emergency Information

If you are unable to care for yourself and have no one to call in an emergency evacuation, please fill out this form and it will be included in Yuba County Public Health's database. We maintain a database that focuses on special populations so that we may aid them during emergency evacuations. All your information is confidential and will not be distributed publicly. Your information will only be used during emergencies. For more information about this form, please contact the Health Department at 530-749-6366. Thank you.

Last Name      First Name
Date of Birth       Male Female
Address      City     Zip
Phone     Insurance Type (i.e. Medi-Cal, Kaiser, Blue Cross)

Allergies

Special Needs

Diagnosis

Pet Assistance Needs: Yes No

Emergency Contact (Name)    Relationship:
Contact Address   Contact City
Contact Zip        Contact Phone

Disclaimer:

By submitting this form you are authorizing Yuba County Health and Human Services Department to disclose and/or use your health information consistent with California and Federal laws for the sole purpose of emergency preparedness. Your information will be put in a secure database and will only be used and possibly disclosed during a state of emergency and/or emergency evacuations without written authorization.

Public Health • 5730 Packard Avenue, Suite 100, Marysville, CA 95901 • (530) 749-6366 • Fax (530) 749-6397

General Comments/Contact