Flood Damage Intake Form
Glide Revitalization represents the Long-Term Recovery Group (LTRG) for Douglas County, working closely with Emergency Management to support community members impacted by disasters. This information will be used to link families to available resources.
Name
First Name
Last Name
Are you currently displaced from your residence?
Yes
No
If yes, please provide details
Staying in a hotel, with family, at the Red Cross Shelter, etc.
Property Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Additional Household Contact
First Name
Last Name
Relationship
Phone Number
-
Area Code
Phone Number
Referred By
First Name
Last Name
Organization
How would you describe the damage to your residence?
Total loss, major damage, minor damage, property/driveway impacted, etc.
What type of assistance best matches your needs?
Debris Removal/Disposal
Home repairs
Driveway/Private Road/Culvert Repair
Landslide clean up
Other
Brief description of current needs:
Ex: Twin size bed and bedding, Refrigerator, Food, Clothing, etc.
Renter/Owner
Rent
Own
Other
Landlord Name (if applicable)
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Flood Insurance?
Yes
No
Other
Is there anything else you would like us to know?
Signature - I consent to my information being shared with partner agencies who can help with recovery resources.
Reminder
Keeping documents and photos are crucial during recovery. Keep all receipts, insurance declarations, and damage records organized in a safe place in case a need arises for them later on.
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: