Physical Assistance Request Form
Please complete this form to request volunteer assistance for storm-related cleanup and debris removal. We will review your submission as soon as we are able. Thank you!
Contact Information
Name
*
First Name
Last Name
Preferred Language
*
Please Select
English
Spanish
Other
Other Language
*
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Address of Property Needing Assistance
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property & Occupancy Information
Do you currently live at the affected property?
*
Please Select
Yes
No
Temporarily displaced
Type of Residence
*
Single-family home
Mobile home
Apartment
Other
Ownership Status
*
Owner
Renter
Family-owned
Other
Is this your primary residence?
*
Please Select
Yes
No
Household Information (select all that apply):
*
Age 65+
Disability or mobility limitation
Chronic illness
Low-income household (self-identified)
No insurance or underinsured
Single caregiver household
None of the above
Disaster & Damage Screening
What type of disaster caused the damage?
*
Please Select
Fire
Flood
Hurricane
Storm
Tornado
Winter Storm
Other
Date of incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brief description of what happened
*
What areas are affected? Select all that apply.
*
Yard
Roof
Fencing
Interior
Garage
Other
Type of assistance requested. Select all that apply.
*
Debris removal
Tree limbs/downed limbs
Light/moderate interior cleanup
Yard cleanup
Fencing Repairs
Roofing repairs
Other
Damage Severity Screening
Which best describes your situation?
*
Minor cleanup (manageable debris, no structural damage)
Moderate cleanup (significant debris but safe access)
Severe damage (roof collapse, structural instability, unsafe areas)
Select any that apply:
*
Active water intrusion or flooding still present
Roof damage or collapse
Unstable walls/ceilings/floors
Exposed electrical hazards
Standing water or mold present
Hazardous materials (fuel, chemicals, asbestos suspicion)
None of the above
Have you received help from any of the following since the disaster?
*
FEMA
Insurance contractor
Church group
Other nonprofit
No assistance yet
Consent & Understanding
Please use the checkbox to show your acknowledgement
*
I understand this is volunteer-based assistance, not professional contracting work.
I understand my request may be declined based on safety or capacity limitations.
I confirm the information provided is accurate to the best of my knowledge.
I understand volunteers may only perform approved tasks within safety guidelines.
Please upload photos and/or a video walkthrough of the damage
Browse Files
Cancel
of
URL of photos/videos
Please describe anything else we should know about your situation (optional)
Submit
Send to Email
example@example.com
Should be Empty: