2019 Disaster Response Nonprofit Contact Form and Service Inventory

Part 1: Organizational and Contact Info

The Nonprofit Center of Northeast Florida is partnering with LISC Jacksonville, the City of Jacksonville and a number of nonprofit partners to organize a more coordinated response to disasters. This work will ultimately result in a coordinated COAD (Community Organizations Active in Disaster) for Duval County to bring enduring structure to the coordination between the nonprofit, public, and private sectors during disasters.

While creating a COAD is under way, the current hurricane season is upon us. If your organization has a role to play - however large or small - we need your help! Please fill out the below survey with your organization's primary contact during a disaster and areas of available assistance.

By filling out this survey, you give the Nonprofit Center, LISC Jacksonville, or the City of Jacksonville permission to reach out to your primary or secondary contact in case of disaster to request information or assistance. No promise of assistance is assumed; it is simply to streamline communication before, during, and immediately after a disaster.

If you have any questions, please contact Deirdre Conner at dconner@nonprofitctr.org or John Sapora at jsapora@lisc.org.

Question Title

* 1. Organization Information

Organization Name

Street Address

City

State

Zip Code

Organization Phone Number

Organization Website

Question Title

* 2. Primary Contact

Primary Contact Name

First

Last

Primary Contact Primary Phone

Primary Contact Cell Phone

Primary Contact Email

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* 3. Primary Contact Communication Preference

Question Title

* 4. Secondary Contact

Primary Contact Name

First

Last

Secondary Contact Primary Phone

Secondary Contact Cell Phone

Secondary Contact Email

Question Title

* 5. Secondary Contact Communication Preference

Question Title

* 6. Additional contacts you wish to receive updates and emails

Name 3

Email Address

Name 4

Email Address

Name 5

Email Adddress

Question Title

* 7. Organization Mission Statement

Question Title

* 8. Does Your Organization Provide Preparedness Training for Clients?

Yes

Question Title

* 9. Counties Your Organization Serves

Baker

Clay

Duval

Nassau

Putnam

St. Johns

Other (please specify)

Question Title

* 10. Which (if any) of the following vulnerable populations does your organization serve?

Seniors

Farmworkers

Homeless persons

Homebound and Medically Fragile Persons

Immigrants/Refugees

Persons with Disabilities

Persons with Children and Single-Parent Households

Persons with Limited English Proficiency

Persons with Pets and Service Animals

Other (please specify)