Please enable JavaScript in your browser to complete this form.Please provide us with your name. *FirstLastPlease provide us with a contact number. No dashes, spaces, or symbols. Just numbers, please!You can elect to provide us with only one point of contact – email or a phone number.Please provide us with your email address.Where were you located at the time of the flood? *Were you impacted by the central Vermont flooding in the summer of 2023? *YesNoAre you filling this form out for yourself or someone else? *MyselfSomeone elseIf you are filling it out for someone else, please provide us with their name, location at the time of the flooding, and your relation to them. Before the flood, what was your housing situation? *RentOwnMobile Home (rented or owned)UnhousedWhat are you future housing goals if you were displaced due to flooding?Repair your homeRebuild your homeRelocate elsewhereHave you applied for FEMA assistance?YesNoNot yet, but I would like assistance to do so.What kind of assistance are you seeking today? You may request multiple grants. Please describe your needs. *You can request mental health support, Laundry Love (provides assistance to pay for laundry services or to replace flood-damaged washers and dryers), Remembering Joy grants (up to $25 per flood-affected family member to cover ticket costs, classes, experiences, adventures, or supplies to help recapture joy), Environmental Health Appliances grants (covers the cost of dehumidifiers, air purifiers, and space heaters for flood-affected households), or cash grants (to cover flood-impacted household needs not listed here). If we've missed an area you need support in, please describe it below.Consent & Release *I agreeI declineAn affirmative “I agree” for this Consent & Release portion of the Rainbow Bridge Community Center’s (RBCC) Rainbow Relief Community Needs Assessment (RRCNA) form authorizes the RBCC to share any information in its possession, including, but not limited to the name, address, and other personal information and the type of assistance being received or requested as a result of the Central Vermont Floods of Summer 2023 with other disaster relief, local government, and voluntary organizations participating in the long term recovery of central Vermont in order to coordinate available disaster relief services and assistance. Consent is not required for assistance and can be revoked at any time. The RBCC will never sell your information. Are you interested in learning how to become a Street Captain? Street Captains serve a vital role in helping their neighborhood prepare and recover from disaster.Yes! Please contact me with more details.Maybe, I’d like to learn more. I’m willing to be contacted.No, thank you.Submit