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Emergency Response Needs Assessment
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C U R R E N T C O N T A C T I N F O R M A T I O N
D E S C R I B E L O S S / D A M A G E
Please state, in plain language, any and all damage to the property
Specify Other Assistance
C U R R E N T N E E D S
Please check all that apply
Move Debris to Street
Duct Work Removal
Clean Under House
Remove Attic Insulation
Remove Insulation Under House
Packing & Salvage of Items
I grant permission for the North Carolina Conference of the United Methodist Church, Disaster Response for Hurricane Florence, to intercede on my behalf to solicit assistance for the above mentioned unmet needs. I understand that the Church does not guarantee any results and only guarantees assistance will be solicited.
(I/We,) indicated by (my/our) signature(s) below, afﬁrm (I'm/we're) the homeowner(s) of the property indicated below. (I/We) give permission to the volunteers of the organization indicated below and its afﬁliated members to work on (my/our) property for the purpose of cleaning out, removing debris, and/or making repairs to (my/our) home.
(I/We) understand that said organization and its afﬁllates do not have insurance coverage for protection against legal claims or liability damage suits that might arise In their work on (my/our) home and property. Therefore, in consideration of the services rendered, or to be rendered, on the premises indicated below, (I/we) hereby waive any and all claims or demands that may arise or accrue to (me/us), growing out of any action or ommissions by said organization and or any/or of its members or helpers in rendering such service and speciﬁcally covenant not to sue it or them for any said act or omissions.
(I/We) agree that by submitting this form electronically, I/We are verifying that decisions to be made on this property are legally allowed. to be me made by the person submitting this form.
Electronic Signature (Type your full name)
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