Disaster Preparedness Survey Form

This information will be used to notify you of any impending emergency that might be affecting our community, and later to contact you to assist you, or to let you know of othersin our congregation who require assistance.

A great resource for Hurricane preparedness is the Collier County Emergency website (www.collierem.org). There you will find the “All Hazards Guide.” Once inside the Guide, you will find a comprehensive list of helpful topics relating to storm safety both before and after the storm.

If you or someone you know would benefit by registering with the County for special needs shelter designation and you require assistance in filling out the paperwork, please leave a message for our committee with Marybeth DeGarmo (239.774.6151) in the church office. A member of our committee will then contact you to assist you in filling out the paperwork.

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Last Name

Number of People at this address

First Names

Address including, Zip + 4

Name of Community/Development where you live

Phone and Cell

Email

Months you typically reside in Naples

Example: October through April

Do you have a family plan in the event of an emergency/evacuation?YesNo

Do you have special needs that would require assistance to evacuate or obtain shelter?YesNo

Do you have pets in your home, and if so what kind?

Have you registered with the County Special Needs ProgramYesNo

Do you need help filling out the County paperwork?First ChoiceNo

Are you dependent on emergency support equipment?YesNo

Please provide an emergency contact that lives outside the immediate area

Include Name, relationship, address, email address and phone numeber

Would you volunteer as a Disaster Preparedness Action Response Team Member?YesNo

Special Equipment

Do you have special equipment which can be used if necessary, such as a truck, travel trailer/RV, generator, chain saw,pump, ham radio, etc If so, please list:

Special Talents?

Do you have special talents that can be utilized following a disaster, If so please list.

Submit