Disaster Relief Request: This information will be provided to Southern Baptist Disaster Relief and they will contact you to assess how we can help to begin the cleanup and recovery.
Note: You still need to register your disaster with FEMA in order to receive Federal Assistance: http://www.fema.gov/news-release/2016/08/14/federal-aid-programs-state-louisiana
First Name *
Your answer
Last Name *
Your answer
Address Affected *
Your answer
City *
Your answer
Zip *
Your answer
Parish *
Your answer
Please specify: *
Mobile Phone *
Your answer
Do you text? *
Email *
Your answer
What church do you attend?
Your answer
Special Needs?
Do you have flood insurance?
Do you have homeowners insurance?
Can work be done without property owner present?
Homeowner permission to take photos of property and damage?
Electricity is
Water is
Gas is
How much water do you know was in your home?
Release (Must be signed before work begins); By printing my name BELOW, I hereby release from liability and agree to hold harmless the Southern Baptist Convention Disaster Relief Volunteers, their representatives, agents and or employees for any damage or injury that may occur on my property, including personal property or to my person, which may occur during the cleanup operation. I further understand and agree that there is no warranty, implied, written or oral, for any work performed on my property by said volunteers. I understand that the Southern Baptist Disaster Relief is a volunteer organization that has limited volunteers, limited financial and material resources, and makes no guarantee that said service will be provided. Additionally, I further understand THAT THIS IS NOT CONTRACT TO PROVIDE SERVICE! *
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