Emergency Information Form for Children with Special Needs

Once submitting the form, Upper Pine River Fire EMS personnel will make an appointment to visit your home to cover any specifics, observe your child in their normal state and get familiar with any technology such as ventilators, feeding systems and ports.

The information on this form is protected by the Health Insurance Portability and Accountability Act of 1996 privacy provisions. Portions of this information may be shared with Emergency Management Official in the event of a Natural disaster or evacuation due to wildfire.

We encourage you to fill out and submit your information via this fillable PDF form to ems@upperpinefpd.com or bring it by the Administration building at 515 Sower Dr., Bayfield,
(970) 884-9508

Fillable/Printable Form

Child with needs playing on the floor with woman

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Upper Pine River Fire Protection District | | 970-884-9508 |