Watering Eden: Clear Air, Clear Water

Watering Eden is committed to protecting the privacy and confidentiality of all individuals completing this intake form. Any information you provide will be used solely for the purpose of identifying and addressing the needs of those affected by the Eaton Canyon fires.

We will not share, sell, or distribute your personal information with any third parties outside of our immediate efforts to coordinate relief and resources. Your responses will be stored securely, and access to them will be strictly limited to authorized team members working directly on this initiative.

If you have any questions or concerns about how your information will be used, please do not hesitate to contact us at info@bstwrt.com.

Thank you for trusting us to assist in this time of need.

With love and care,
Brianna "B." Stewart
Founder

Sign in to Google to save your progress. Learn more
Personal Information
Full Name *
Address Affected by Fires *
Phone Number *
Email  *
Preferred Method of Communication *
Household Information
Are you the head of your household?
 *
How many people are currently living in your household? Please specify adults and children. *
Do you have any elderly members (65+) or individuals with specific health needs in your household? *
Impact Assessment


How have the fires affected your living situation?
Clear selection
Do you currently have access to clean drinking water? *Not bottled*
Clear selection
Do you currently have access to an air purifier?
Clear selection
Support Needed
Which items do you need most urgently?
Would you prefer delivery or pickup for the items? 
Clear selection
Are you in urgent need of other essentials such as new clothing, water, etc? *
Would you like a make-up kit pick me up? Provided by our friends at LOreal and Urban Decay. *
Fire Area
Which fire directly impacted your current living situation?
Clear selection
Did your local water company issue a "Do-Not-Use" order after 1/7/2025? 
Clear selection
Feedback and Community Involvement
Would you be willing to share your story anonymously to help raise awareness for this fundraiser?
Clear selection
Are you interested in volunteering or contributing to Watering Eden's efforts in the future?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Mazique.

Does this form look suspicious? Report

Google Forms