Voluntary Registry for Persons Requesting Additional Assistance

Building Coordinator:      
Name:    Assistance Location(s):    
E-mail:    Assistance Location Phone:   
Primary Phone:    Emergency Contact Name:   
Address:   
 
  		 Emergency Contact Number:   
Title:     

 

Emergency Notification 

 

Types of Assistance Requested                                                          

 
Fire / Building Evacuation:    
Severe Weather:    
Shelter-in-Place:    
Other (specify):    

 

 

 

 
 
1000 ASU DRIVE   |   ALCORN STATE MISSISSIPPI 39096-7500   |   PHONE: 601.877.6100