Multi-Agency Resource Center Intake
Please take a few minutes to fill out the electronic form to provide information about your living situation. You will only have to fill out this survey once and it should take about 5-10 minutes.

After completing survey, please bring a form of identification to the registration table after completion to sign the waiver to meet with organizations.

If you are not able to fill out the survey or need assistance, please visit the registration table.

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MARC Location - (Event Location) *
Required
Today's date *
First Name *
Last Name *
DOB *
MM
/
DD
/
YYYY
Affected Address *
SPELL OUT ENTIRE ADDRESS AND INCLUDE CITY, STATE, ZIP CODE - (Street Number) (Street Name Spelled Out), (City), (Zip Code) EX: 1315 Ann Avenue, Saint Louis, MO 63104
County *
Affected Address
Are you Living in the Affected Residence?
NO = Displaced due to the tornado; If business or non-living space = N/A
Clear selection
Contact Address - *If Different*
IF DIFFERENT  ----   SPELL OUT ENTIRE ADDRESS AND INCLUDE CITY, STATE, ZIP CODE - (Street Number) (Street Name Spelled Out), (City), (Zip Code) EX: 1315 Ann Avenue, Saint Louis, MO 63104. *If contact address is the same as the affected address, input "Same address"
Phone Number *
Secondary Phone Number
E-Mail Address
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