* 1. What is your full name?

* 2. What is your civic address?

* 3. Have you run out of water at home?

* 4. Do you believe you are at risk for running out of water?

* 5. Please indicate what type of well you use:

* 6. Would you be willing to offer assistance to those without water? (i.e. filling water jugs, etc.)

* 7. If yes, please enter your contact information.

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