Disaster Reception Center Intake Form Disaster Reception Center Check-In Form This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.About YouYour Name(Required) First Last Your age(Required)Your Address (address where damage occurred)(Required) Street Address Address Line 2 City ZIP Code How Can We Reach You?Preferred Method of ContactEmailPhoneYour Email Address(Required) Email Address Confirm Email Address Your Phone(Required)Please tell us who else lives in this homeSpouse name, if applicable First Last Spouse ageNames of other adults living in your household, including children age 18 and up Name Age Actions Edit Delete There are no People. Add Person Maximum number of people reached. First names and ages of children in your home under the age of 18 Name Age Actions Edit Delete There are no People. Add Person Maximum number of people reached. Do you own any pets? Dog(s) Cat(s) Bird(s) Reptile(s) Other No, no pets in this home Home damageWhere do you plan to sleep tonight?(Required) Our home with family or friends hotel in the shelter in our vehicle unknown Was your home damaged?(Required) Yes No Unknown How would you describe the damage to your home?(Required) Minor Moderate Major Unknown Do you own or rent this home?(Required) Own Rent Neither – I am a guest in this home Do you have insurance for this property?(Required) Yes, homeowner’s insurance Yes, renter’s insurance No, I have no insurance on this property Did you have particular requests for services?(Required)NameThis field is for validation purposes and should be left unchanged.
