Kehewin Emergency Management Data Collect Survey

Membership Data

Kehewin Covid 19 Emergency Management is Seeking important data on it's membership.

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* 1. Your Full Name

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* 2. Address

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Are you or any members in you home at risk?

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* 4. Would you like to receive information updates via

Text

Email

Voice Calls

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* 5. Allergies or food requirements?

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* 6. Number of members and ages in the home

Total Number of members:

Ages:

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* 7. Are you Currently in need of assistance?

What kind of Assistance

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* 8. Would you like to have follow up to this survey?

Yes, Phone Call

Yes, Email

No, I'm Good