Member Support Survey

If you have lost your housing, or have had to evacuate (either long-term or short-term) please fill out this form to let us know your immediate needs.

We will do our best to provide you with donated items based on your requests.

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Email Address

Question Title

* 4. Phone Number

Question Title

* 5. How were you affected by the fire?

Lost Housing

Evacuated/Displaced - Short-Term

Evacuated/Displaced - Long-Term

Other (please specify)

Question Title

* 6. Please let us know what items you/your family need? Please be as specific as possible (groceries, children's clothing, gas, etc.).

Question Title

* 7. Are you able to pick-up your donations from the WGAW Building (7000 W. 3rd St.)? Please note: being unable to pick-up your donations will not exclude you from this program.

Yes

No (let us know how we can get the items to you)

Member Support Survey

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Email Address

Question Title

* 4. Phone Number

Question Title

* 5. How were you affected by the fire?

Question Title

* 6. Please let us know what items you/your family need? Please be as specific as possible (groceries, children's clothing, gas, etc.).

Question Title

* 7. Are you able to pick-up your donations from the WGAW Building (7000 W. 3rd St.)? Please note: being unable to pick-up your donations will not exclude you from this program.

Question Title

* 8. Is there anything else you'd like to share with us?