Voyage Church Outreach: Request Help

IN IMMEDIATE DANGER? CALL 911. Do not use this form for emergencies.

Tell us what you need after the hurricane and a coordinator will contact you. Please fill in one form per home.

Your name *

Best phone number to reach you *

Street address *Include the house number.

Town *

Who is this request for? *

Me or my householdSomeone else

What happened, and what do you need? *

Is anyone hurt, trapped, or in need of medicine or oxygen? *

If yes and it cannot wait, call 911 now.

NoYes

Are power lines down, or do you smell gas? *

Stay well away from any downed line and report it to your power company.

NoYesNot sure

Is a tree on the house, or is the roof open to rain? *

NoYesNot sure

Can you safely stay in the home tonight? *

YesNoNot sure

Does the home have homeowners insurance? *

We ask because some volunteer groups can only work at homes without insurance. Your answer does not change whether we help you.

YesNoNot Sure / I’m filling this out for someone elseI rent this home

How soon do you need help? *

If anyone is hurt, trapped, or in danger, call 911 now. Do not wait for us.

Low: it can wait a week or moreMedium: we need help in the next few daysUrgent: we need help in the next 24 hours

Who lives there?For example: elderly, children, medical needs, pets.