CommsConnectUS - EMERGENCY ASSIST REQUEST




Please complete this form to the best of your ability. We understand that during severe emergencies some of this information may not be known.
Once received, the information will be processed, and the CCUS-Ops Team will attempt to locate and respond someone to assist.

Please note that ASSISTANCE IS NOT GUARANTEED.








How many people need assistance at this address?

Affected's Name:
Phone Number:
Address:
City:
State:
Zip:
Last Known Contact:
Comments (Any additional useful information):

CommsConnectUS, CommsConnectUS-“Partner Groups”, and Assignees RELEASE FROM LIABILITY/HOLD HARMLESS:
By continuing forward, you hereby acknowledge that you a willing participant in CommsConnectUS and its programs, and understand, acknowledge,
and accept that this service is voluntarily accepted and administered. By continuing forward, you understand, acknowledge, and accept that
CommsConnectUS, its “Partner Groups”, nor any assignees guarantee the safety of, nor accept responsibility for, any CommsConnectUS participants’
safety during CommsConnectUS service cycles, and hereby release CommsConnectUS, CommsConnectUS-Partner Groups, and all assignees from any
liability and address to HOLD HARMLESS, all assignees, and hereby acknowledge and accept the terms as outlined above.

Your Contact Name:
Your Phone Number:
Relationship: