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.
Client Information
Name *
Your answer
Best Phone Number *
Your answer
Best Time to Call
Best Email:
Your answer
Co-Applicant / Emergency Contact Name :
Your answer
Contact phone number of Co-Applicant / Emergency Contact Name.
Your answer
Relationship to Applicant:
Applicant's F.E.M.A ID Number:
Your answer
Applicant's Red Cross ID:
Your answer
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? *
Required
Number of adults in the home affected by the disaster over the age of 18? (18 or Over)
Your answer
Number of children in the home affected by the disaster under the age of 18? (17 or Younger)
Your answer
Pre-Disaster Housing Information
Pre-Disaster Housing Information: *
If Secondary Residence was selected above, was this used as a vacation rental?
Street Address of Home affected : *
Your answer
City of Home affected : *
Your answer
State of Home affected : *
Your answer
Zip Code of Home affected : *
Your answer
County of Street Address *
Pre-Disaster Estimated value of your home? (What was the value of your home before the fires? )
Your answer
Mailing Address (If different than the property affected ) 1234 Name St, City, State, and Zip Code
Your answer
County of Mailing Address:
Your answer
Type of Dwelling: *
Current Housing Information
Current Housing Information:
Current Housing Address (Only fill out If different than the property affected ) 1234 Name St, City, State, and Zip Code *
Your answer
County of Street Address (If county not listed please enter in the section labeled "other" ) *
Risk Assessment
Risk Assessment
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