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Hurricane Evacuation Form - 4/29/2019 -

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Please fill out the following information to help us ensure the safety of your family member in the event of an evacuation.
Please print and mail back to:

River Oaks Retirement Manor

2500 East Simcoe Street Lafayette, LA. 70501
 
Resident Name: ________________________________
 
Emergency Contact Information: 
 Name: _________________________________________ 
 Work Phone: __________________________________ 
 Home Phone: _________________________________ 
 Cell Phone: _______________________ ____________ 
 Email: _________________________________________ 
 Other: _________________________________________ 
 
 
Do you want to take your family member in the event of an evacuation?  

 YES ______       NO_____
 
Signature ___________________________ Date:  ____________


 

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