Personal Emergency Evacuation Plan form

Complete this form at least 48 hours in advance of the wedding/civil partnership/citizenship ceremony. You will need to complete a form for each person with a disability or mobility issues attending on the day.

Name of person completing this form*

Email*

Ceremony details*

Name of person with disability or mobility issues*

Mobile phone number*

Name of friend or family member assisting*

Name of registrar or usher assigned to provide assistance*

Details of disability or mobility issue

Are they visually impaired?*

Yes
No

How severe is the visual impairment?*

Do they require help to evacuate the premises?*

Yes
No

Do they have a hearing impairment?*

Yes
No

How severe is the hearing impairment?*

Do they require help to evacuate the premises?*

Yes
No

Are they a wheelchair user?*

Yes, permanently
Yes, occasionally
No

Do they use a manual or powered chair?*

Manual
Powered

Can they transfer from the wheelchair to an evacuation chair?*

Yes, with no assistance
Yes, with assistance
No

Are they able to get down stairs and out exits safely in an emergency?*

Yes, completely independently
Yes, with some support
Yes, with support and evacuation chair
No

If the person is not a wheelchair user, what other mobility aids do they use?*

Crutches
Walking stick
Walking frame
None

Are there any further impairments or disabilities that may affect their ability to evacuate the building during fire alarm activations?*

Yes
No

Give details of these impairments or disabilities*