Evacuee Registration Form

This form is for NWT residents who need to evacuate—or be prepared to evacuate—due to an emergency or disaster.

One registration may be used for individuals or households. You must complete all the questions asked for every member of the household. Family members who live in a different location must register separately.

The Evacuee Registration portal contains personal information that cannot be used without consent from the individual for whom the personal information belongs.

For more information and resources about what to do in case of an evacuation, go to: www.nwtalert.ca

Address Information

Community being evacuated from *

Physical street address *

If you do not have an address please provide a lot number or description of where you live.

Unit, suite, apt#

Contact Information

Cell phone number (preferred) *

Please enter a cell phone number (not a landline) that can be used to contact you during an evacuation or enter N/A if you do not have a cell phone.

Alternative phone number

Email (optional)

I give my consent to receive email updates in the event that I need to evacuate.

Email address

Emergency Information

Emergency contact name *

Emergency contact number *

Personal Information

Do you have a legally registered single name? *

Single name

First name

Middle name

Family name

Date of birth *

Month

Day

Year

Preferred language *

Evacuation Information

In the event of an evacuation order, go to www.nwtalert.ca to find out where the designated evacuation centre for your community is located.

I will be going to the designated evacuation centre.

I will need transportation from my home community to the evacuation centre.

I will bring a service animal to the evacuation centre.

I will require special assistance once I arrive at the evacuation centre.

Applicant Declaration

I declare that the information that I have provide is true and accurate.

I understand that personal information contained on this form is collected under Annex A Evacuation Guidelines of the NWT Emergency Plan, and may be used by the local Emergency Management Organization to provide appropriate supports in the event of an evacuation due to an emergency or disaster. If you have any questions about the collection or disclosure of your personal information, please contact the Emergency Management Organization at 867-767-9161 ext 21020 or nwt_emo@gov.nt.ca.

Attention
If you have any questions please reach out to your community government.