Disaster Relief Beneficiary Intake Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Contact Number
Email Address
Address
Street Address
City/Town
State/Province
ZIP/Postal Code
Country
Household Information
Total Household Members
Vulnerable Group Members (children, elderly, disabled, etc.)
Disaster Impact
Type of Disaster
Flood
Earthquake
Storm
Fire
Drought
Other
Brief Description of Damage/Needs
Urgent Needs