Hurricane Harvey / Damage Report & Help Request
We are sorry to hear that you have been affected by Hurricane Harvey. Citymark Church is praying for you and we want to partner with you as best we can to help in this time of need.

The purpose of this form is so that Citymark Church can assess damage sustained by those from Citymark Church or friends of Citymark Church.

First and Last name *
Your answer
What's the best email address for you? *
Your answer
What's the best number to reach you? *
Your answer
What is your primary form of contact?
What is your secondary form of contact?
Address: *
Your answer
How are you connected with Citymark? *
Are you (or a family member) in a Citymark connect group? *
Who is your connect group leader(s)?
Your answer
Do you have shelter for your family?
Where are you currently?
How many people are in your family?
Your answer
What are your material needs?
Please list any specific items needed (What size and gender of clothes and/or shoes)
Your answer
Do you have an immediate financial need?
Please share any helpful details or specific amounts you may have an urgent need for (i.e.; a bill; urgent supplies, groceries, gas, etc.)
Your answer
What kind of damage does your home have?
How would you describe the damage and its extent? (Ex: Flooding of 5ft in my home which required rescue; flooding of 6 inches in my downstairs; both cars and house are flooded, unsure of extent of damage, etc.)
Your answer
Do you own or rent your home?
Do you have flood insurance?
Do you have renters insurance?
Is your immediate family together?
Do you have transportation now?
Did you have a car flood?
If yes, do you have: (check all that apply)
Did you lose all your vehicles?
Do you know any other Citymark family in need? Please list their name and contact information.
Your answer
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