Stronger TOGETHER Name * First Name Last Name Property Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Preferred mode of contact Phone Email Text Who owns the property? * Owner occupied Rental Both What role would you be willing to serve? * 1) Network member (means that you will share your information with this network); 2) Neighborhood Lead (means you are the first contact if neighbors need help, and are willing to help support social events and informal meetings to discuss procedures in the case of an emergency); 3) Block Captain (requires incident command training from the fire department, willingness to follow directions and implement emergency procedures. Network Member Neighborhood Lead Block Captain Are there elderly (over 80) or handicapped persons likely to be in this residence In summer? Yes No Does anyone in your household have any special training? How did you hear about us? Word of mouth Boothbay Register Online Southport Island Association Event Other Do you have any questions or concerns? {If so please tell us if you would like to discuss them with a Southport Climate Action Team member, and how we should contact you.} Thank you!
