Courthouse Community UMC Congregational Disaster Census

Each United Methodist Church is called by the Virginia Conference to implement a Disaster Response Plan.  This census will help us to respond to that call.  We need information about your household to create a data base and a mapping source for use in times of emergencies.  We also need information on your gifts, talents and resources.  This information by no means commits you to any future disaster work without your OK.  Please complete the census to the best of your ability.  We thank you in advance for your cooperation.  Remember, it is important that you take care of yourself and your family first and foremost in times of crisis.

Simply Fill in the blanks or check a box. If information does not apply please leave blank.

Household Name:     

Persons over 18 in Household:

Person 1: 

Person 2: 

Person 3: 

Person 4: 

Street Address: 

City:    State:   Zip: 

Home Phone:    Cell Phone:   Other: 

# of children living with you under 18 years old: 

Child 1: 

Child 2: 

Child 3: 

Child 4: 

Child 5: 

Child 6: 

Child 7:  

Would you need assistance to evacuate, if necessary:     Yes        No

In case of emergency contact (closest relative NOT living with you):

Name:    Home Phone:  Cell Phone:

Street Address: 

City:   State:   Zip:  

I can serve my Church/Community after a disaster in the following ways.   On the next page please check all your gifts, talents and resources that apply (please continue):

Clean Up

Persons From Above Listing:

1        2        3        4

            I own a Chain Saw.

            I know how to use a Chain Saw

            I can help with debris removal

                                     (yard waste/other)

Lifting Capabilities

1        2        3        4

            Lifting < 15 lbs.

             Lifting Appliances

              Lifting Furniture

              Lifting Carpets

Powerwasher

1        2        3        4

              I own a pressure washer.

              I know how to use a pressure  

                                      washer.

I am familiar with the Demolition of the following:

1        2        3        4

            Sheetrock

             Studs

             Windows

             Flooring

             Roof

             Tree removal

            Entire structures

Tools & Equipment Appliances

1        2        3        4

             Generator

             Shovel

             Rake

             Ax

             Pick

             Power Saw (Battery or Electric)

             Power Drill (Battery or Electric)

             Other:   

 Vehicular:

1        2        3        4

             Four Wheel Drive

             Uncovered Trailer

             Covered Trailer  

             Mobile Home / Camper

             Boat

             Other:  (Please List any type of tools you could provide that we missed):

 

Persons From Above Listing:

1        2        3        4

           YES,  I have all the necessary

                                        information I need for a disaster.

Temporary Repairs

Persons From Above Listing:

1        2        3        4

             Board up windows

             Tarp Roofs

             Clear/build drainage

 Heavy Equipment – Experienced

1        2        3        4

             CDL Licensed

             Backhoe

             Bobcat/skid loader  

             Bulldozer

             Cherry picker

             Folk-lift  

             Heavy truck driver

             Mechanic

             Stump grinder  

             Tractor/wagon

Meals

1        2        3        4

              Preparation

              Cook

               Serve / Clean Up  

Other Skills:

1        2        3        4

           Team Leader

           Child Care

            Computer / Advanced  

           Computer Data

            Damage Assessment

            Intake – requests for help  

            Intake - Volunteers

            Transportation - Driver

            Communications  

            Translate (Language):

            Translate (Language):

            Translate (Language):

            Translate (Language):

             American Sign language

            Pack Items for Storage  

            Ham Radio Operator

            Job Assignment Coordinator

            Other:  (Please List any type of labor you could provide that we missed): 

 Persons From Above Listing:

1        2        3        4

           NO,  I do not have all the necessary  information I need for a disaster (send me something)

 1        2        3        4

           If no, would you be willing to attend a symposium where information is presented (date TBD)?

 

For all those over 18 years old please sign and date, Thank You for your participation.

 

Person 1:   Name:      Date:

Person 2:   Name:      Date: 

Person 3:   Name:      Date:

Person 4:   Name:     Date:   

(Please contact the Church Office if any information changes on this census.  We need to keep our data current.)