Disaster and Community Crisis Recovery Form

Primary Contact First Name *

Last Name *

Job Title or Role *

Email *

Phone Number *

Secondary Contact First Name

Last name

Job Title or Role

Email

Phone Number

Organization Name *

Organization Street Address *

Organization/Company City *

Select your Organization/Company's state *

Organization Type: *

Nonprofit

Municipal agency (public schools, public parks, Other city agency)

For profit entity

Other

Was your community disrupted by a natural disaster or crisis? If yes, please explain. *

Did the natural disaster or crisis happen at a location that is different than your organization’s address? If yes, please list the address below.

Briefly describe the impact to kids and the community you serve, including any playspaces (your own or others if applicable), your physical location, programs and services. *

Are you currently operating in your normal location or a temporary one? *

Normal Location

Temporary Location

Do you have photos, news article links or anything else you’d like to share about the disaster or crisis impact your community has sustained? If so, please email these items to [email protected] . Please put your organization’s name and the phrase “Disaster impacted group” in the subject line.