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2. Belvedere Disaster Preparedness Household Information Form
   Please take a moment to complete our online Household Information Form. We encourage all Belvedere residents to register their information, including block captains. Our goal is 100% participation. If you need help completing the form, please contact Belvedere City Hall and one of our staff members will assist you.
4. Download OK/HELP Banner
   OK/HELP Banner (PDF)

   In addition, please print out our OK/HELP banner and store it somewhere safe. In the event of a disaster, this banner should be placed in a prominent position in your residence so that it is visible from the street. This will allow our block captains to quickly ascertain who needs assistance.
6. Is this your first time registering?

   1. This is my first time registering my household.
   2. I have already registered and need to change my information. (Please complete the full form with your new information; your prior registration will be deleted and replaced)
8. Name (Adult 1)*
9. Name (Adult 2)
11. Street Number*
12. Street Address*
    -- Select One --Acacia AvenueAlcatraz AvenueBarn RoadBayview AvenueBeach RoadBella Vista AvenueBellevue AvenueBelvedere AvenueBelvedere WayBlanding LaneBritton AvenueBuckeye RoadCliff RoadCove RoadCove Road PlaceCrest RoadEdgewater RoadThe EmbarcaderoEucalyptus RoadFern AvenueGolden Gate AvenueHilarita CircleLagoon RoadLaurel AvenueLeeward RoadMadrona AvenueMallard RoadMarin AvenueMaybridge RoadNorth Point CircleOak AvenueOak PlacePelican Point RoadPeninsula RoadPomander WalkSan Rafael AvenueTamalpais AvenueTamalpais CircleTeal RoadToyon AvenueWest Shore RoadWindward Road
13. Apartment Number/Letter
15. Primary Phone Number*
16. Home Phone Number
18. Cell Phone (Adult 1)
19. Cell Phone (Adult 2)
20. Additional Phone Number
22. Email Address (Adult 1)
23. Email Address (Adult 2)
25. Number of Adults Living at your Address
    -- Select One --12345678+
26. Number of Children Living at your Address
    -- Select One --012345678+
28. Do you have any pets? If so, please describe
30. Do you have a water well?

    1. Yes
    2. No
31. Do you have an electrical generator?

    1. Yes
    2. No
33. Do you, or anyone in your household, have any specialist training that may be useful in a disaster situation e.g. medical, military, rescue etc. If so, please describe.
35. Do you, or anyone in your household, have any special needs that may mean you need additional assistance e.g. hearing/vision impairment, mobility issues? If so, please describe.
37. Please describe the location of your water shutoff.
39. Please describe the location of your electricity shutoff.
41. Please describe the location of your gas shutoff.
43. Is there anything else you would like to tell us about your household?
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field