Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
1. Are there children in the house under 18?
Yes
No
How Many
2. Are any children on free or reduced lunch?
Yes
No
3. Select If Any
Veterans
Seniors 65 or Older
Disabled
4. Have any of your family been eligible for SNAP benefits in the last 3 years?
Yes
No
5. Have you or anyone in your house rode the RTA?
Yes
No
6. Does this house have an internet provider?
Yes
No
If Yes, Which provider
7. Does this house use home internet or mobile hotspots?
Home Internet
Mobile Hostspot
Neither
8. Has your electric bill ever gone over $150-$214?
Yes
No
9. Would you be interested in technology to help lower your bills for utilities?
Yes
No
10. Do you or your spouse own a state registered business?
Yes
No
11. Do you feel you have been impacted by climate change? More flooding, increased heat, more wind storms?
Yes
No
12. Do you own any pets in this location or do you plan on owning a pet soon?
Yes
No
Back
Next
If answered yes to owning pets answer 13-19. if not, skip to question 20
13. Would you like a professional opinion on the living expenses for the pet you want/own?
Yes
No
14. Do you have access to cool water for your pets?
Yes
No
15. Do you use any water misting, fans or other devices to cool pets more often because of heat?
Yes
No
16. Has your pet shown signs of excess heat stress, shaking, drooling, heavy breathing, and a lack of appetite?
Yes
No
17. Do you have access to a neighborhood dog park, via NORD, near you?
Yes
No
18. Is there a veterinary clinic in your area?
Yes
No
19. Would you be open to going to a reduced or free veterinary clinic or care event?
Yes
No
Back
Next
20. Would you be interested in gardening, tree planting, beautification, jobs or efforts around climate change in your neighborhood?
Yes
No
21. Would you be interested in volunteering?
Yes
No
22. Want to be updated about things in the neighborhood,?
Call
Text
Email
Submit
Should be Empty: