Emergency Response Needs Form

***PLEASE READ*** Please complete this form to help the Eaton Fire Response Team come to a decision about potential aid for a community member's need. Only Epicentre Members, Lifegroup Leaders, or Epicentre Staff should complete this form. The Eaton Fire Response Team has a limited budget and distribution will be made on a first-come, first-serve basis and is based on fund availability. Please be as detailed as possible as the information you provide will be used as supporting documentation to the approval team, if funds are approved. ALL INFORMATION WILL BE KEPT CONFIDENTIAL.

For person in need.
Please provide another form of contact like email or other phone number.
If other phone number, supply contact name/relationship. i.e. work number, family member, etc.

Check all boxes that apply.

i.e. event name, activity, location, date/time, etc

Check all that apply.

If any. If not attending, then N/A.

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