Resource Family Disaster Plan Form

AGAPE RESOURCE FAMILY DISASTER PLAN
RESOURCE FAMILY NAME:*
Home Study Writer*
Home study writer is assigned after training is completed. If you have not completed training, please mark "Other or Unknown."
Should my family need to leave my home address due to a natural disaster or catastrophic event, the following plan will be implemented:
If I need to evacuate my home, my first plan would be to relocate to: (Friend or family if relocating to a residence)
(Name of family/friend/other)
(Address)
Telephone Number
Alternative Telephone Number
Other Contact Information/email
My alternative location would be:
(Name of family/friend/other)
(Address)
Telephone Number
Alternative Telephone Number
Other Contact Information/email

Emergency Contact
(Name of family/friend)
(Address)
Telephone Number
Alternative Telephone Number
Other Contact Information/email
I understand that there are critical items I am urged to take with me when we evacuate, including:
- Case Manager emergency contact numbers
- Children's medical information (e.g., Prescriptions, recent med records, M.D's name/phone and immunization records)
- Educational Records
- Important Documents such as Birth Certificates, Social Security Cards, Marriage Licenses, Insurance
I understand that I am required to check in with the AGAPE Case Manager at the following numbers:
- AGAPE: (615) 781-3000
- Supervisor cell: (615) 294-6141
I understand that I will update any changes to this information with my case manager within fourteen (14) days of any change.
Signature of Resource Parent

Clear
Date

MonthDayYear
Date
Printed Name
Should be Empty: