Intake Form
The Ventura County Long Term Disaster Recovery Group (VC LTDRG) is a collaboration of more than 50 organizations working to address unmet needs through volunteer assistance, in‐kind donations as well as, in some cases, financial aid. Please complete this intake form to start the process and a 2-1-1 Outreach team member will contact you to discuss your needs and get you connected to resources and assistance for which you qualify.
Sign in to Google to save your progress. Learn more
Client Information
Name *
Date of Birth *
Best Phone Number *
Best Email:
Best Time to Call
Alternative Contact Name:
Alternative Contact Phone Number
Relationship to Applicant:
Clear selection
Applicant's F.E.M.A ID Number:
Applicant's Red Cross ID:
Consent to Share Info: *
VC LTDRG does not share personal contact information unless we receive explicit permission from the individual. We request consent to share between select partner organizations working on disaster case management (The Salvation Army, Jewish Family Service, 211 Ventura) to streamline assistance.  
Were you affected by Thomas, Hill or Woolsey Fires? *
Number of adults in the home affected by the disaster  over the age of 18? (18 or Over)
Number of children in the home affected by the disaster under the age of 18? (17 or Younger)
Pre-Disaster Housing Information
Pre-Disaster Housing Information: *
Street Address of Home affected : *
City of Home affected : *
State of Home affected : *
Zip Code of Home affected : *
County of Street Address *
Pre-Disaster Estimated value of your home? (What was the value of your home before the fires? )
Mailing Address (If different than the property affected ) 1234 Name St, City, State, and Zip Code
County of Mailing Address:
Type of Dwelling: *
Current Housing Information
Current Housing Information:
Clear selection
Current Housing Address (Only fill out If different than the property affected ) 1234 Name St, City, State, and Zip Code *
County of Street Address (If county not listed please enter in the section labeled "other" ) *
Risk Assessment
Risk Assessment
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy