Emergency Notification Form

Every year, Port Coquitlam homes receive an Emergency Notification Form with their water and sewer bill, and are asked to provide medical information or cautionary notes about themselves and/or their property to help firefighters if an emergency occurs.

In particular, residents requiring special assistance in the event of an emergency evacuation are asked to complete the form.

Submit an Emergency Notification Form

There are three ways to submit your Emergency Notification Form:

  • Complete the online form below
  • Download the PDF version [PDF/370KB] of the form
  • Go to Fire Hall #1 (1725 Broadway Street) during operating hours (Monday to Friday from 8 am to 4:30pm) to fill out a paper copy of the form

Note: Please only fill out the form if you have something to report, as forms containing blank, “None”, “N/A”, etc. in both of the Person(s) and Circumstance(s) fields will not be entered into our CAD system. Likewise, information that falls within our normal operating procedures will also not be entered.

For assistance with this form, please contact 604.927.5466 or email [email protected].

Form Submissions

Forms only need to be submitted if there is a medical need, mobility issue, cautionary notes or special access instructions to report.

The form must be submitted annually. Information from the previous year is automatically deleted from the system each April to ensure the information is up to date.

Personal information entered on this form is collected under the authority of Section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA) for the purposes of processing your input. If you have any questions or concerns about the collection of this information, please contact the City’s Records and FOIPPA Administrator at 604.927.5250 or [email protected].

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