Disaster Intake Form – Community Recovery Team

Service Territory

Before you start!!
We serve only San Diego County.
Your zip code must appear in the list below.

Zip Codes (click list and type your zip code). *

Personal Information

Completed By Completed By

Last Name

First Name

Language Language

Are you the
head of household? *

No

Yes

Your age

Number in Family

Are you in the Military

Yes

No

Do you Have Access & Functional Needs?

Yes

No

Are you part of vulnerable population?

Yes

No

Addresses

Disaster Address

City

State/Province

Zip/Postal

Country

Current Address

City

State/Province

Zip/Postal

Country

Contact Information

Primary Email

Secondary Email

Home Phone

Work Phone

Cell Phone

Alt. Phone

Emergency Contact Name

Emergency Contact Phone Number

PROPERTY INFORMATION

Was your home destroyed or damaged?

Are you owner
or a renter?

Type of
Home?

Are you
insured?

Ownership
of Land? Ownership<br />of Land?

Have you registered
with FEMA?

Notes