Wildfire Recovery Assistance

Please complete this form so our team can contact you.

Please complete this short form so our team can contact you. We may request more information afterward. Submission does not guarantee assistance.

Full name *

Phone number *

Email address

Current address *

City

ZIP code

Preferred contact method Call Text Email

Do you have a fire card? * Yes No

Was your home or property affected by the Brantley County wildfires? * Yes No

Current housing situation Camper/RV With family/friends Other

# Adults (18+)

# Children (1-17)

# Infants (under 1)

Household member ages (ages only — no names)

Is anyone in the household currently employed? Yes No Prefer not to say

What assistance do you need? (Select all that apply) Temporary housing / camper Household supplies Food Other

Other assistance needed

Are there any medical, mobility, disability, or accessibility needs we should consider?

I confirm the information is accurate to the best of my knowledge and give Hope for Brantley permission to contact me about my request. *