Member Support Survey

If you have lost your housing, or have had to evacuate (either long-term or short-term) please fill out this form to let us know your immediate needs.

We will do our best to provide you with donated items based on your requests.
1.First Name
2.Last Name
3.Email Address
4.Phone Number
5.How were you affected by the fire?
6.Please let us know what items or support you/your family need? Please be as specific as possible (groceries, children's clothing, gas, storage, housing, etc.).
7.Do you need help with tasks such as filling out forms, making calls, doing research, running errands? Please specify the support you're looking for.
8.Are you able to pick-up your donations from the WGAW Building (7000 W. 3rd St.)? Please note: being unable to pick-up your donations will not exclude you from this program.
9.Is there anything else you'd like to share with us?
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