Room Air Purifier Distribution Application

Wallowa County Air's mission is to provide residents with air quality information and mitigation strategies for smoke intrusions, while continuing to improve our wildfire resiliency and natural resources in Wallowa County.

Wallowa County Air, through grants from Oregon Department of Environmental Quality and Lewis-Clark Valley Healthcare Foundation, is offering free air purifiers to citizens of Wallowa County, prioritizing smoke vulnerable residents.

Citizens will be screened based on existing medical conditions, age-based smoke vulnerability, and income.

Applications will close at 5:00 PM on June 14th. You will be notified withing a few days of closing, if you qualify. Please complete the application below to establish eligibility for your household. If you have any questions, please contact Wallowa County Air at wallowacountyair@gmail.com or 937-418-3620.

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* 1. Contact Information

Name *

Physical Address *

Address 2

City *

State *

ZIP Code *

Email Address

Phone Number *

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* 2. Enter your mailing address if different than your physical address.

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 3. How were you referred to the Air Purifier Distribution Program?

Social Media

Flyer picked up at medical facility

Direct mailing

Flyer at senior meals locations

Website

Other (please specify)

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* 4. In whole dollars, please list your gross annual income from all household members.

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* 5. Mark the number of people in each age category that live in your household. Smoke has different risks for people of different ages.

	1	2	3	4	5+
0-5 years old	0-5 years old 1	0-5 years old 2	0-5 years old 3	0-5 years old 4	0-5 years old 5+
6-10 years old	6-10 years old 1	6-10 years old 2	6-10 years old 3	6-10 years old 4	6-10 years old 5+
11-15 years old	11-15 years old 1	11-15 years old 2	11-15 years old 3	11-15 years old 4	11-15 years old 5+
16-64 years old	16-64 years old 1	16-64 years old 2	16-64 years old 3	16-64 years old 4	16-64 years old 5+
Over the age of 65	Over the age of 65 1	Over the age of 65 2	Over the age of 65 3	Over the age of 65 4	Over the age of 65 5+

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* 6. Does anyone in your household regularly smoke or use e-cigarettes inside your home?

Yes

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* 7. Is anyone in your household currently pregnant?

Yes

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* 8. Please select the number of household members that have respiratory issues (COPD, Asthma, Smoke Allergies) or cardiovascular issues?

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* 9. Is wood heat a primary heat source in your house?

Yes

No, but it is a secondary heat source

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* 10. Please type your full name to certify all the information you have provided on this application is true and accurate to the best of your knowledge.