Shelter Is Golden

Shelter Is Golden > Guest Enrollment Form

Name *

Address *

City *

State *

Zip *

Home Phone *

Cell Phone

DEMOGRAPHIC PROFILE

Number of Residents

Age/Gender of Adults

Number of Children

Age/Gender of Children

Whom would you prefer to be sheltered by?

Preferred age of shelter host(s):

How many days would you need to be sheltered?

Is there a cultural preference?

Is there a religious preference?

If you wish to bring housebroken pets, please describe:

LIFESTYLE PROFILE

Would you refrain from smoking or drinking alcoholic beverages if requested by your host?

If anyone in your household has special medical or diatary needs, please describe:

If anyone in your household is disabled, please describe:

ONCE EVACUATION BECOMES NECESSARY

I would be willing to bring

Food and Drink (including special needs)
Linens and Towels
Soap, shampoo and related toiletries
Pet Food (if applicable)
Pet Equipment
Medications and Related Equipment
Sufficient money for expenses
Clothing
Identification/emergency contact list
Other:

Any other comments or relevant information you wish to add?

* Denotes required inputs.