2021 Snowstorm response

General

In order to best serve the community after the winter storm of 2021, please answer the questions below.

Once your information has been received, a team of volunteers will review your input and ensure your application is sent to the most appropriate service organization.

Question Title

* 1. General Intake

Name

City/Town

State/Province

Email Address

Phone Number

Question Title

* 2. What county do you live in?

Question Title

* 3. Race/Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other:

Prefer not to answer

Enrolled Tribe (if applicable):

Question Title

* 4. Household

Number of Seniors 65+

Number of adults 18-64

Number of children 0-17

Total number of household members

Number of household members with a disability

Number of household members who are a veteran or active military

Question Title

* 5. In order to make the most appropriate referral, please indicate your currently annual household income:

Under $15,000

Between $15,000 and $25,000

Between $25,001-$35,000

Between $35,001- $45,000

Between $45,001-$55,000

Over $55,000