Displacement Intake Form

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Please fill out this form if you have been displaced by Hurricane Sally

Your Name *

Do you rent or own your home? *

Rent

Own

If you rent, who is your landlord?

What day did you become displaced? *

YYYY

Have you contacted FEMA? *

Yes

Are you homeless or in temporary shelter? *

Yes

How many adults and children total are in your household? *

Do you have children under the age of 18? *

Yes

What is your budget for shelter?

Do you have pets? If so please list breed, number of pets, etc.

How many bedrooms are required for your needs? *

Are you financially able to put a security deposit down? *

Yes

Maybe

Are you seeking new or better employment and would you like assistance in this? *

Yes but I do not want assistance

Yes I am and need assistance

Does a member of your household have a disability requiring specific care? (Wheel chair accessibility, etc.) *

Yes

Are you, or a member of your household a veteran?

Yes

Other:

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Is there anything specific our volunteers need to know about your situation that would help us in providing better help to you?

What is the best way to reach you? *

Our team will work to help your family and address its individual needs. The information in this form will be shared with our volunteers so they may provide you the best information possible. Please note we are not able to guarantee assistance, merely direct you to resources the best we possibly can with those provided. We are not directly affiliated to any one organization or agency. *

I have read and understand the above.

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