WNC Hurricane Helene Needs Request Form

WNC Hurricane Helene Needs Request Form

Please use this form if you are making a request for assistance. Please fill out as many details as you can so we can meet your need in the best way. If you are filling this out on behalf of someone else, please be as thorough as possible.
Are you filling this form out for yourself or on behalf of someone else?

MyselfI'm filling it out for someone else.
Person Filling Out the Form
What is your name?

First NameLast Name
What is your email?
example@example.com
What is a good contact phone for you?
Please enter a valid phone number.
What is the date of the request?

MonthDayYear
Date
If you are filling this out on behalf of another person where did you see the need posted?

FacebookOver a signal/chat threadDirect request from someone I am in contact withOther
If you saw this need posted on social media or a signal/chat thread, did you follow up with the person to verify the need has not yet been me?

YesNo

Info of person in need of assistance
What is the name of the person that needs assistance?

First NameLast Name
What is the location you or someone needs assistance? (Leave this field blank if you don't have an address or do not want to give your address, but please at least give us your general area)

Street Address

Street Address Line 2

CityState / Province

Zip
County
What is a good phone number?
Please enter a valid phone number.
Is there any other contact info that is best to use?
Is there someone else we can contact, what's their number? Is there an email or social media account we can contact you at? If so, what's your email, username or handle?
Preferred Language

Category of work
Which category of help is needed? (you can choose multiple categories)*

Medical SupportGet SuppliesWater DeliveryTree Work/Road ClearingHouse Muckout/Mold/RepairOther

Medical Support
What medical support do you need?

I need help medical attention (physical or mental health)I need help getting medical supplies (Oxygen, prescriptions picked up from pharmacies)
How urgent is your situation?

This is an emergencyI need help in the next day or twoI need help within the week
Describe what you need?
Be as specific as you can, some examples of things to tell us: Any symptoms, injuries, or flare ups of existing medical conditions. You can also ask for us to bring you medical supplies, such as your

General Supplies Info

Please list what supplies are being requested. We will do our best to meet these needs based on current supplies at local distribution centers.
How many people need supplies?
Some examples of things you could ask for:
- Shelf stable food
- Cleaning and household products
- Generators, solar panels, charge bricks
- Fuel
- Chainsaw supplies
- Baby supplies
- Pet supplies
- Toiletries
- Muckout gear (Tyvek suits, respirators, PPE, tools, contractor bags),
- Camping gear
- Camping stoves and propane
- Cold weather clothes
- Blankets and sleeping bags
What do you need? (Please enter only ONE item per line. Use the "Add Row" button to request multiple items.)
When do you need the supplies?

In the next day or twoWithin the next weekWhenever they come in, I'm flexible
Do you need supplies delivered, or can you get to a distribution site?

I need them deliveredI can get to a distro site
If you need a delivery, when is a good time to bring things?

Tree Work/Road Clearing
Please describe your situation (e.g. tree on house, tree blocking access) and ability to pay (e.g. need pro-bono work, sliding scale, can pay).
Let us know in as much detail as possible, and we can send an arborist crew to come check it out.
Please upload any photos below.

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House Muck Out/Mold/Repair

We are working on setting this up this infrastructure, but there are other groups in the area that are already doing this work.
What happened to your house?
Did a tree fall on it? Did your house and/or basement flood? Do you need any rebuilding? Or just mucking out your house? Please describe what happened to the house and what damage there is.
Any Photos?

Cancelof

Other Requests

We have a limited scope of what existing crews are working in the area, but tell us what other support you need and we will try and either find someone local who can help or connect you to another group that is already doing that work.
What other support do you need?

Final Info
How can we get to you?

Any car4WD Car4WD High Clearance TruckATV/Side by SideHelicopterWalking
Do you have any special instructions for meeting this need?
Examples: "I want a Spanish Speaker" or "I Want Someone from My Community to Help"
Anything else you need us to know about this request?
Should be Empty:

Person Filling Out the Form