Membership Interest Form
Thank you for completing our Membership Interest Form!
This form is not a membership application, but the first step in our process. We’re prioritizing families most affected by the Eaton Canyon Fire first and will review all submissions carefully. Our small team will follow up with next steps as soon as we can. Thank you for your patience!
Sign in to Google to save your progress. Learn more
First Name  *
First Name
Last Name  *
 Last Name
Email Address *
Email Address
Age/Grade *
Required
Pronouns (optional)
Current School *
Where do you live now? Current Town/City + ZIP Code
Please complete below
Town/City: *
ZIP Code: *
Where did you live before the Eaton Canyon Fire?
Please complete below
Town/City (pre-fire) *
ZIP Code (pre-fire) *
Impact from Eaton Canyon Fire (Check all that apply) *
Required
Wellness Check-In
Use a Likert scale: 1 = Not at all, 5 = Extremely
I feel anxious or overwhelmed today *
Not at all
Extremely
I’ve been sleeping well lately *
Not at all
Extremely
I have someone I can talk to if I need support *
Not at all
Extremely
Emergency Contact
Complete the information required below
Name *
Phone number *
Something We Should Know?
Feel free to share it below
Is there anything you'd like to share with us today?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of altadenagirls.org.

Does this form look suspicious? Report

Google Forms