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2. 
3. Disaster Assistance Center Intake Form
5. *This form is designed to collect data to help the county address unmet needs, but is not a guarantee of assistance. Data collected will be used to help justify potential programs that may become available.
6. Please check the box indicating you understand the statement on the left.*

   1. I understand
8. First Name
9. Last Name
10. Email Address
12. Address
14. City
15. State
16. Zip Code
18. Phone Number
20. Primary Residence

    1. Yes
    2. No
21. Was your home

    1. Damaged
    2. Destroyed
23. Do you

    1. Rent
    2. Own
24. Do you have homeowners/renters insurance?

    1. Yes
    2. No
26. Current Address

    If you are not staying at your primary residence

28. City
29. State
30. Zip Code
32. PREFERRED LANGUAGE
34. Disability or Access and Functional Need (if you'd like to share that with us)
38. Do you have pets?

    1. Yes
    2. No
39. Quantity and species of pets
41. Are they staying with you?

    1. Yes
    2. No
42. Are they at the Spokane County Fairgrounds?

    1. Yes
    2. No
44. Do you anticipate needing longer term assistance with care? If yes, please give brief description.

    food, supplies, place to stay...

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field