Request edit access
IA 728 Free Power Drops
If your home has been affected by the fires and you are currently without power, please fill out this form and we will contact you to coordinate bringing you a battery pack or putt-putt generator. 
If you have significant power needs, please note and we can discuss the option of a tow plant.
Sign in to Google to save your progress. Learn more
Full Name *
Phone number and/or Email address (we will be contacting you via this method.) *
Address where power is needed *
Is this location inside an evacuation zone? If "Yes", please answer follow-up question below *
If "Yes" to question above, do you have the ability to travel to the nearest checkpoint and receive supplies?
(Please note: "No" does not disqualify you from power drops. We just need to know in order to coordinate with the fire department for escort into the zone.)
Clear selection
What is this location? *
Are you the owner/current resident of this address? If "Other", please specify your role in relation to the address. *
What needs power? Please specify as much as you can. (eg. lights, phone charging, appliances, etc.) *
Preferred date of drop-off *
MM
/
DD
/
YYYY
Preferred time of drop-off (if any)
Time
:
Anything else we should know or be aware of
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms