Disaster Assistance Request Form

Disaster Assistance Request Form

Fill out the form below and we will respond as soon as possible. Requesting assistance via this form does not guarantee BDR's ability to fulfill all needs. We will do our best to help or connect individuals and families with other relief resources.
•Applicants must be within a declared state of emergency or disaster boundary.

I understand and agree.
•We may find it necessary for some people asking for assistance to be able to provide proof of residence in the form of photo ID and/or piece of mail/utility bill with your name, town and state visible. Additional verification methods such as referrals may be requested in certain situations.

I understand and agree.
•Fraudulent requests will not be tolerated or honored. BDR will review all requests for accuracy before providing assistance.

I understand and agree.
Name

First NameLast Name
Primary Phone Number
Alternate Phone Number
Email
example@example.com
What communication options do you currently have available in the location you currently reside?

Landline phone service at my residenceCell service at my residenceCell service at a nearby locationInternet service at my residenceInternet service at a nearby locationNo phone or internet service at or near my residence.I have phone at internet service when I am at work or another location that I frequently visit.
Location Where Assistance is Needed:*

Street Address Line 2

CityState / Province

Postal / Zip Code
Street Address (optional):
Community or Neighborhood:
As a result of Hurricane Helene, are you requesting assistance from BDR with any of the following?:

Debris & Fallen Tree CleanupDriveway GradingOther Dirtwork, such as ground leveling or hillside gradingChainsaw workGravel DeliveryDemolition
As a result of Hurricane Helene, are you in need of assistance with any other of the following?

I need propane and would like to be part of the BDR free SMALL and MEDIUM propane tank program. (available for delivery or pickup)I need help with DELIVERY of a tiny house, temporary shelter, or camper delivery.I need help FINDING a tiny house, temporary shed shelter, or a camper.I need other basic supplies such as heaters, food, toiletries, diapers, fresh water, clothing, and blankets.Other
As a result of Hurricane Helene, please describe any challenges you have had which have hindered your ability to recover from the storm.*
Do you own the property where service (e.g. debris assistance, grading, dirtwork, demolition, etc.) is be requested?*

YesNo
Please describe in detail what needs you have in relation to any debris assistance, grading, dirtwork, demolition, etc.*
Please describe where the gravel is needed and an estimate of how much gravel you will need.*
We are planning to provide as much free assistance for delivery and grading of gravel as possible, but can you afford to pay something for the cost of the gravel that will be delivered?*

YesI may be able to pay something towards the cost of the gravel.No
If possible, please provide photos in jpg or png format showing the areas needing debris assistance, grading, dirtwork, etc. (Multiple files can be uploaded.)

Cancelof
Do you have power at your current residence?*

Yes, I have grid-power.I have limited power access via generator, solar, etc.No, I have no access to power, including generators or solar.
Are you using propane as your primary heating/cooking source?*

YesNoI have access to some power or other heating sources, but I am relying on propane to support my basic heating/cooking needs.
How much propane do you estimate you use each week during the winter?*
How many and what size propane tanks do you currently have that are available to swap out for full tanks?*
What damage was caused to your home as a result of Hurricane Helene? *
Are you still living in the residence that was damaged by Hurricane Helene?*

YesNo
Do you plan to eventually move back into your home?*

YesNoMaybe
Please describe any health or safety concerns or other issues at your original residence.*
What is your current living situation after moving out of the residence affected by Hurricane Helene? Please describe any health or safety concerns or other issues at your new residence.*
Do you have power at the location where the tiny house, temporary shed shelter, or a camper will be located?*

YesI will have limited access to power via generators, solar, etc.No, I will have no access to power.I am not sure if I will have access to power at the location.
Will the tiny house, temporary shed shelter, or camper be located on property that you or your spouse own?*

YesNoI am not sure where it will be located yet.
Where will the tiny house, temporary shed shelter, or camper be located? Who's property will it be on? Please explain your relationship to the property owner. *
Has the property owner already given you permission to place your tiny house, temporary shed shelter or camper on their property?*

YesNo
Property Owner First Name:*
Property Owner Last Name:*
Property Owner Phone Number:*
Property Owner Email:*
Please describe what resources, such as heaters, fuel, water, clothing, toiletries, etc that you are looking for. *BDR is primarily a volunteer camp, and is not a supply hub, but we do have some limited supplies available, as well as the ability to network with other disaster relief groups to find other supplies and resources.*
Are there any obstructions impeding access to your location? If so, please describe access issues and also provide alternate travel directions if necessary.*
Other comments or questions:
By submitting this form, I attest that all details provided are true to the best of my knowledge. I understand that any false or delayed information could slow down or prevent help from being provided. I understand that Burner Disaster Response (BDR) may not be able to provide help in every situation, including, but not limited to terrain access impediments, resource access, logistical limitations, or Requestor's non-compliance with timely communication and cooperation.
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