Storm Relief Request

Storm Relief Request

Please fill this form out as completely as possible.
Seven Rivers Church exists to bring the love of Jesus to broken people in broken places. When storms hit, we work to mobilize a group of volunteers to respond to the initial relief needs in Citrus County. We do not have the volunteer capacity to provide long-term relief efforts, and filling out this form does not guarantee that you will receive help from Seven Rivers Church. We will do our best to evaluate the immediate needs and respond accordingly.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Connection to Seven Rivers Church*

MemberRegular AttenderAttend Group at SRC (MomCo, GriefShare, DivorceCare, etc.)Other
Is this your primary residence?*

YESNO
Are there any medical or mobility issues?*

YESNO
If there are medical or mobility issues, please describe them in detail.
Are there children living in the home?*

YESNO
If there are children living in the home, please list their ages.
Is there a single mother living in the home?*

YESNO
Is there a widow living in the home?*

YESNO
Are there friends and/or family that can assist with this request?*

YESNO
If there are friends and/or family that can assist, please list their name(s) and contact number(s).
Current Needs (please check all that apply)*

Removing furniturePulling out carpetPulling up flooringClearing out mud/water from the homeRemoving personal itemsRemoval of trees affecting home or carDrywall removalYard pickupHelp getting to local services
If you have a need that is not listed above, please describe in detail what the need is.
Should be Empty: