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MY TRIBE RISE - Altadena Community Care Form
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* Indicates required question
First Name
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Your answer
Last Name
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Your answer
What is your phone number?
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Your answer
What is your email?
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Your answer
Are you displaced? What city are you staying in right now? Include if you are being housed by family, friend, hotel, AirBNB, etc?
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Your answer
What is the address of your lost or fire-impacted home? Please indicate if you own or rent.
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Your answer
What is your race/ethnicity?
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Your answer
What are your main needs right now? (money, housing, transportation, basic needs, paperwork or legal assistance, therapy, less isolation?)
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Your answer
Have you already attended My TRIBE Rise's Immediate Cash Assistance events?
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yes
No
What is your annual household income?
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$0 - $20,000
$21,000-$40,000
$41,000-$60,000
$61,000-$80,000
Over $80,000
Other:
Would you like to share your story (about your family's life in Altadena) as part of our oral history project?
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Yes
No
Do you have questions you would like asked to County / City Officials?
Your answer
If you lost your home in the fire, would you like to share a photo of what it looked like before the fire as part of the My Tribe Rise Altadena Memory Wall and Archive?
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Yes
No
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