Survivor Intake Form - EmergencyRV
This form will help us collect the information we need to add families to our waiting list for an RV. Please keep in mind we are a group of volunteers working as hard as we can to help as many people as we can. We may have to ask you to provide documentation to verify the information that you have provided so please be honest and truthful. All responses will be kept personal and confidential within EmergencyRV unless we get written consent from you to share your story.
Name of Contact (head of household) *
Phone number where you can always be reached *
Email address *
Where are you currently living? (Conditions- i.e. hotel, motel, friend’s house, shelter, tent, car, etc.) *
Total number of people living in your household at the time of the event: *
Total number of children living in your household: (under 18) *
Total number of adults living in your household: (over 17) *
Please list the ages and genders of everyone in your household. Ex. 20yrF, 2moM, 25yrX *
Are you a single parent? *
Are you a first responder? (Fire, EMT, Police) *
If applicable, Please describe your first responder work. (We will require documentation)
Are you a US military veteran or active military? (We will require documentation) *
If applicable, please describe your military service (branch, dates, combat/deployment, etc.)
Do you have any serious medical conditions? If yes, please describe. Don’t forget to include if you have trouble with stairs! *
Did you rent or own your home? *
Do you have insurance on your home? (Renters Insurance or Homeowner Insurance) *
Please list the complete address of the home you lost. We may require that you provide a bill or piece of mail in your name to document this address. *
Please tell us the event that caused you to lose your home (ex. The camp fire of 2018 or hurricane Katrina, etc.) *
Please add anything else you would like for us to consider relevant to our evaluation of your application for the use of an RV.
If we are able to secure an RV for your family, do you have somewhere you can park it? *
Please advise your preference: *
The RV is the sole property of EmergencyRV and by filling out this form, you agree to return the RV to EmergencyRV in good working condition once you have found a permanent housing solution so that we are able to help other survivors. *
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