Jefferson County Evacuees Check In
This form is for Jefferson County residents who were evacuated during and immediately after the catastrophic flooding caused by Hurricane Harvey. Information gathered will be used for the sole purpose of assisting county and city officials with the development of plans to return Jefferson County citizens to their homes. Your information will not be sold or used for any other purpose.
First Name *
Your answer
Last Name *
Your answer
Home Street Address *
Your answer
Home City *
Home Zip Code *
Your answer
Contact Phone Number *
Your answer
Email
Your answer
Do you have an alternative contact person? *
If yes, please provide their name and phone number.
Your answer
Did you evacuate with family or friends? *
If yes, please provide the names and ages of the people who are with you.
Your answer
Was your home damaged as a result of Hurricane Harvey? *
If yes, do you have alternative housing for when you return to Jefferson county?
Where are you currently located? Please be as specific as possible. Include address and contact information if available. *
Your answer
Will you need assistance to return to your hometown? *
Do you have school age children? *
If yes, provide the number of school age children you have.
Your answer
If yes, what school(s) do they attend?
Your answer
Share Your Story (Optional)
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms