Emergency Self-Identification Form

The purpose of this form is to provide information regarding persons with special needs to first responders in the event of an emergency. Submitting this form does not guarantee the execution of each specific request articulated below. MSM makes every effort to maintain the confidentiality of information disclosed in this form. MSM encourages community members with special needs to create a Personal Emergency Plan – a plan for what they will do in the event of an emergency.


The School recognizes that individuals with disabilities may require assistance with alerting, evacuating, and sheltering in the event of an emergency. The School therefore asks all individuals who may need assistance in an emergency to consider all or some of the following options for preparing for an emergency:
 
• Self-identify themselves to the School by completing and submitting a Confidential Self-Identification Form.  
 
• Cooperate in developing a Personal Emergency Plan.
 
• Identify “buddies” to serve as rescue assistants during emergencies.
 
• Plan to communicate with Campus Safety when frequenting School buildings, especially during off-hours.
 
• Provide electronic contact information to the School to facilitate notifications during an emergency.