Agency:

Contact Person:

Mailing Address:

City:    State:    Zip:

Phone:    Fax:

E-mail:

Hours of Operation:

Number of Paid Staff:    Number of Volunteer Staff:

Please select all that apply to your organization:

        There are current staff with First Aid certification

        There are emergency supplies on site

        Staff with medical needs keep extra supplies on hand

        Our building is earthquake safe and fire safe

        Agency records and documents are regularly backed up and kept off site

        Our agency has an up-to-date disaster response plan

        Staff keep copies of their family disaster plans on site

        Staff have a posted plan for contacting one another after a disaster

        Our agency is prepared to continue service to clients after a disaster

If you have not checked all of the boxes, would you like SFCARD to assist?YesNo

Would your agency like to:

        Receive information about SFCARD meetings and training sessions?

        Take part in a city disaster training exercises?