For the Family - Building A Stronger Community Through Its Families

Name *

Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Email

Age/Gender of Children

Number of Children

Age/Gender of Adults

Number of Residents

HOUSING PARAMETERS

Type of Construction

Year Constructed

Square Footage

Number of Bedrooms and Bathrooms

Is the a history of flooding?

Are you in an Evacuation Zone? If so provide the zone.

Do you have hurricane window protection (not including tape)?

If not, is there a windowless room(or rooms) with a full door large enough to house all occupants?

Do you have a generator?

Do you have a Disaster Preparedness Plan?

SHELTER PARAMETERS

Number of Adults you can comfortably host (in addition to yourselves):

Preferred age of adults:

Number of Children you can comfortably host:

Preferred age of Children:

How many days would you be willing to accommodate guests?

What housebroken pets would you accommodate?

Cats
Dogs
Other:

Preferred age of adults:

If more than one pet, please note how many and what kind:

Please note preferred Breed, Gender, and Age:

Please check any personal preferences that apply

Non-Smoker
Non-Drinker
Other:

Would you be willing to provide shelter in disasters other than hurricanes?

Is there a cultural preference?

Is there a religious preference?

Would you be able to shelter individuals with special medical needs or disabilities?

If yes, please describe capabilities to accommodate wheelchairs, walkers, or other specialized needs:

What should guests bring with them?

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
Other:

Any other comments or relevant information you wish to add?

* Denotes required inputs.

Shelter Is Golden

Shelter Is Golden > Host Enrollment Form