How Can You Help When Disaster Strikes?
In the event of a disaster like Hurricane Harvey, the information you provide will help Good Shepherd stay in touch and provide assistance. It also lets us know specific ways you and you family can help. When we combine all of our resources, we are a powerful source. Thank you for taking the time to complete this survey.
Information About You and Your Family
This will allow us to contact you and provide any needed assistance.
First Name
Your answer
Last Name
Your answer
Email Address *
Your answer
Cell Phone Number (if you do not have a cell phone please provide the cell number of someone close to you who does) *
Your answer
Work Phone Number (if applicable)
Your answer
Landline Phone Number (if applicable)
Your answer
Spouse First Name
Your answer
Spouse Last Name
Your answer
Spouse Cell Phone
Your answer
Spouse Email Address
Your answer
Spouse Work Number
Your answer
Names and ages of children living with you, other household members, or anyone we may contact if you need assistance. Please include cell phone numbers if applicable.
Your answer
Your Family's Home Address *
Your answer
Subdivision/Village
Your answer
Major intersection closest to your home
Your answer
Emergency Contact (First and Last Name)
Your answer
Emergency Contact Cell Phone *
Your answer
Emergency Contact Email *
Your answer
In case of an emergency like a hurricane, where is your family most likely to go?
Your answer
Do you or anyone in your family have special needs that may include lack of mobility, use of wheelchairs, or other assistance? Please explain.
Your answer
Ways That You Can Help
Please provide details of any resources or assistance you would be willing to provide in the event of a hurricane or other disaster.
Please check any items, skills, or services that you would be willing to provide in an emergency.
Please provide more information about the resources above such as how many people could you accommodate at your home, what supplies you could provide, etc.
Your answer
Professional Skills and Services - Please provide details of any medical services (MD, Nurse, EMT, First Aid, etc), legal assistance, counseling, and/or construction assistance you and/or your spouse would be willing to provide.
Your answer
Thank you for taking the time to provide this information. It will be used to coordinate the response to emergencies so that we as members of Good Shepherd can better serve one another.
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