The Church Disaster Preparedness program does not replace emergency services provided by government agencies. However, our disaster preparedness program is concerned with your welfare and your personal situations. We are also concerned about our church property, the community, and other communities. This survey form will assist the church Disaster Preparedness Committee to identify individuals that need assistance, and individuals that wish to volunteer their services. It is important that all members respond to this request. Your church wants to be prepared in case of an evacuation, emergency, or disaster. As you are aware, recent disasters have proven that those who were prepared had a much better chance for survival. Direct questions about this form to Jim Kirk.
Last Name Number of people living at this address
First Names ,,,,,,
Address City , State Zip+four
Name of Community/Development that you live in
Phone Cell Phone E-Mail
Months that your are typically in Naples through
1. Do you have a family plan in event of an emergency or evacuation? Yes No
2. Do you have special needs that would require assistance to evacuate or obtain a shelter? Yes No
3. Do you have pets in your home, and if so what kind?
4. Have you registered with the County Special Needs Program? Yes No
5. If you have not registered, do you need help filling out the county paperwork? Yes No
6. Are you dependent on emergency support equipment? Yes No
7. Please provide an emergency contact that lives outside the immediate area.
Name Relationship
Address
City , State Zip+four Phone
8. Would you accept church families who may be required to evacuate? Yes No If yes, how many?
9. Will you accept smokers? Yes No Will you accept pets? Yes No
If yes, are there any restrictions? Please list
10. Would you volunteer as a Disaster Preparedness Action Response Team member? YesNo
11. 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.?
YesNo If yes, please identify:
12. Do you have special talents that can be utilized following a disaster?
