SMM Disaster Preparedness Assistance Request
This form is being used by SendMeMissions, Inc. [a 501(c)3 non-profit faith-based organization] to help assist Hardee County Families that are in need of disaster preparedness help before hurricane season or a specific storm. Priority is given to individuals with disabilities, elderly, single parents with infants or special needs children. Please make sure that you have been given permission to submit someone else's information and they are aware that we will be contacting them. This form does NOT guarantee assistance, but instead helps us make contact with individuals to assess the situation.
Email address *
Have you submitted a Disaster Preparedness Request to any other state, private, church or volunteer agency? (If yes, click other and list who you submitted with already) *
Who is submitting request... *
If filling this form out on behalf of someone else, please list your Agency Name, Contact Person & Number. (i.e. Hardee Help Center, John Doe, 863-773-0000)
Name of person needing assistance *
House Number and Street Name *
Apt #
City *
Zip Code
Phone Number # (with area code) *
Other information that will help us locate the address.
Do you have a church home? If yes, please list here:
Eligibility for Special Considerations (mobility, age) *
Required
What type of preparedness assistance do you need help with? *
Required
Anything else we need to know:
Disclaimer
This website, its services, and associated individuals or entities are not liable for damages, including loss of life, limb, or property. This website is not affiliated with any government organization. It is a volunteer-run website, and is meant and advertised as a best-effort, Good Samaritan initiative. Call 911 for emergencies.
Submit
Never submit passwords through Google Forms.
This form was created inside of SendMeMissions. Report Abuse