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
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)
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: