JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Emergency Comfort Center (ECC) Check-In
Use this form to check-in visitors to an Emergency Comfort Center (ECC) which includes shelters, warming, and cooling centers.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full Name
*
Your answer
Phone Number
Your answer
Zip Code
Your answer
Age
Your answer
Guardian Information
If Visitor is a Minor, please fill out this info!
Your answer
Sex
Male
Female
Prefer not to say
Other:
Clear selection
ID Number
*
This can be a Driver License or State ID number or a pre-generated ID Number used at the shelter.
Your answer
Reason for Visit
*
Medically Necessary
Unhoused
Power Outage
Extreme Heat
Extreme Cold
Other:
Immediate Needs
Your answer
Notes About Visitor
Your answer
Check In Time
*
Time
:
AM
PM
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Clay County, WV CERT.
Report Abuse
Forms
