GTD CERT Questionnaire

6283 Main Street

Georgetown, CA 95634

This questionnaire is designed to help our community during emergencies. This information is voluntary and will be used to assist GTD CERT with the potential needs your household may have.

Form Submission Type

Date

Name (First)

Name (Last)

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState

Zip Code

May need assistance with:

Briefly describe your needs during an emergency.

Emergency Contact For You (First and Last Name):

Phone

Format: (000) 000-0000.

Relation

Are you able to help your neighbor if needed:

If so, descibe how you could help: wellness check, supplies, etc

Under normal conditions is your location easily accessible?

In extreme winter weather could your location access be limited?

If yes, please explain

Would you like to be contacted by a CERT member to discuss your needs?