Health Care Facility Emergency Management Portal
Health Care Facility Emergency Management Portal
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Facility Registration
Facility Name:
*
Facility Type:
*
Adult Day Care Center
Ambulatory Surgical Center
Assisted Living Facility
Hospital
Intermediate Care Facility
Nursing Home
Residential Treatment Center
Residential Treatment Facility
Skilled Nursing Unit
Fire Jurisdiction:
*
Daytona Beach
Daytona Beach Shores
Debary
Deland
Deltona
Edgewater
Holly Hill
Lake Helen
New Smyrna
Oak Hill
Orange City
Ormond Beach
Pierson
Ponce Inlet
Port Orange
South Daytona
Unincorporated Volusia
Location Address:
*
City:
*
Zip Code:
*
Mailing Address (if different than Location Address)
Mailing Address
*
City:
*
Zip Code:
*
Facility Phone:
*
Emergency Phone:
*
Administrator/Owner Contact:
Contact Name:
*
Office Phone:
*
Cell Phone:
*
Office E-Mail:
*
Create Portal Account
Alternate Administrator Contact:
Contact Name:
*
Office Phone:
*
Cell Phone:
*
Office E-Mail:
*
Create Portal Account
Safety Liaison Officer Contact:
Contact Name:
*
Office Phone:
*
Cell Phone:
*
Office E-Mail:
*
Create Portal Account
Portal Account Contact:
Contact Name:
Office Phone:
Cell Phone:
Office E-Mail:
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