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(Required)

Email(Required)

Ceremony details(Required)

Name of person with disability or mobility issues(Required)

Mobile phone number(Required)

Name of friend or family member assisting(Required)

Name of registrar or usher assigned to provide assistance(Required)

Details of disability or mobility issue

Are they visually impaired?(Required)

Yes
No

How severe is the visual impairment?(Required)

Do they require help to evacuate the premises?(Required)

Yes
No

Do they have a hearing impairment?(Required)

Yes
No

How severe is the hearing impairment?(Required)

Do they require help to evacuate the premises?(Required)

Yes
No

Are they a wheelchair user?(Required)

Yes, permanently
Yes, occasionally
No

Do they use a manual or powered chair?(Required)

Manual
Powered

Can they transfer from the wheelchair to an evacuation chair?(Required)

Yes, with no assistance
Yes, with assistance
No

Are they able to get down stairs and out exits safely in an emergency?(Required)

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?(Required)

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?(Required)

Yes
No

Give details of these impairments or disabilities(Required)