Jefferson-Chalmers WATER Project Contact List and Comment Thread

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Contact List: Provide us with your information and we will include you in invitations to meetings and events as well as website updates and other important announcements.

Comment Thread: If you have an Ideas, Suggestions, Questions, Comments or Constructive Criticisms, we'll post with your initials and respond on the Jefferson-Chalmers WATER Project as quickly as possible.

First Name *

Last Name *

Email Address *

Address (# Street) *

City *

Zip Code *

Age

Gender Identity

Own or Rent Your Home *

Home Owner

Renter

Do You Have a Mortgage?

Yes

Other:

Clear selection

Do You Currently have Flood Insurance?

Yes

I Need Assistance in Securing Flood Insurance

Clear selection

What percentage of Your Monthly Payment is Your Flood Insurance (Example: $100 Flood Insurance Divided by $500 Total Monthly Payment = 20%)

Have You had Your Water Service Line Replaced? *

Yes

Other:

Have You Signed Up for DWSD's Basement Protection Program? *

Yes

Other:

If Yes, which Choice have You Selected? *

Backflow Preventer Inside

Backflow Preventer Outside

Sump Pump

Is Your Backflow Preventer or Sump Pump Installed? *

Yes

Are You Willing to Assist in Advancing the Jefferson-Chalmers WATER Project?

Canvass - Distribute Fliers

Host Meetings at Your Home, Church or Organization

Help Organize and Recruit Neighbors

Donate or Help Raise Funds

Administrative Work - Make Calls, Update Data Base, Make Copies, Etc.

Other:

Clear selection

Are you interested in supporting the WATER Project's Committees?

Water Quality - Working with area youth to sample, test and interpret water quality in Fox Creek

Flood Protection - Remove the community from floodplain, assist with recovery resources

Permits - Participate in renewal, identify monitoring and notification requirements

Coalition + Partner Outreach - Assist in identifying, outreach to residents, stakeholders and partners

Other:

Clear selection

Ideas, Suggestions, Questions, Comments or Constructive Criticisms

How did you find out about the WATER Project?

Flier or Poster

Neighbor, Friend or Colleague

NextDoor

Other Social Media (Facebook, Instagram, etc.)

Community Organization (ECN, D4 Disaster Committee, Jefferson East, etc.)

Other:

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms