Request For Assistance

Your safety and well-being are our top priorities. Please complete this form to request assistance after a natural disaster. All information you provide will be confidential and used solely to assist you during this difficult time.

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Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Disaster

Date / Time

Family Need

Checkboxes

I hereby authorize Rise Orange County, a Long-Term Recovery Group, to release any information maintained by the Long-Term Recovery Committee that is relevant for the purpose of providing assistance for my disaster needs to the agency or person designated.
I further understand that the release of information does not guarantee that assistance will be provided, but that without the information my case cannot be presented to the Long-term Recovery Group for consideration.
I authorize a designated agency or person to release any information maintained by the agency or person that is relevant and necessary for my case to be considered by the Long-Term Recovery Group.

Name