Fire Safe Community Membership Application

FIRE SAFE COMMUNITY QUESTIONNAIRE

Shelly Black is leading a Fire Safe Community, assisting homeowners in creating and being a part of a FireWise USA Neighborhood, which aims to develop a coordinated and cohesive community that is united and prepared for disasters.

Shelly is offering these services as an Independent Contractor-Fire Liaison Specialist who is seeking to assist Bear Valley residents in becoming Firewise USA certified.  She is also promoting fire preparedness, mitigations, disaster preparedness, individual evacuation plans, as well as neighborhood networking through community collaboration.

So, she can better serve you, please complete the following questionnaire:

Name ________________________________________________          

Cell Phone ____________________________________________

Address ___________________________________________________________________________           

Email _____________________________________________________________________________

Track & Lot #   _____________________     Lot Size________ # of Residents _______  

1.     # and type of Pets & Livestock    __________________________________________________________________________________

2.     Does anyone in your home need special assistance or have special medical needs? Y  N

3.     Do you keep a to-go bag ready all year around? Y  N

4.     Do you have crates and horse trailers ready to evacuate all your pets? Y  N

5.     Do you have an evacuation plan that includes scenarios for 5 minutes notice versus a 2 day notice?  Y  N

6.     Do you have a place to evacuate that can take all your pets?  Y  N

7.     Are you familiar with the Bear Valley CSD evacuation plans?  Y  N

8.     Do you have water tanks and/or generators to use in an emergency?  Y  N

9.     Do you have fire retardant gel for protecting your structures?  Y  N

10.  Do you have any skills that you would like to offer for fire mitigation in your community?  Y  N  If so, please list here: _________________________________________________________________________________________

11.  Would you charge for your fire mitigation services, such as landscaping, hardscaping, and clearance? Y  N

12.  Do you have any skills that you would like to offer during an emergency or evacuation?  Y  N  If so, please list here: _________________________________________________________________________________________

13.  Are you an active or retired First Responder, Medical professional, Police, Fire or EMT professional?  Y  N 

14.  If so, are you interested in being available to respond in emergencies within your community?  Y  N

15.  Are you interested in having your property be a part of the volunteer Firewise USA Community Program?  Y  N

Additional Comments: __________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Together we can thrive and survive! We can be an example and a success story - working together for the greater good of us all. BVS can be the Largest Firewise Community in the Nation.

** Important - the FirewiseUSA Program is a volunteer program that is free and available to all California Residents. There is no fee to participate in, or create, a FirewiseUSA Neighborhood. This Annual Membeship fee is to participate in Shelly Blacks' Fire Safe Community, which within that Community, members are taken through the process to become Nationally Certified in the FirewiseUSA Program.

I wish to contract with Shelly Black, as an Independent Contractor Leading a Fire Safe Community Program, within which she will assist me in creating a Firewise USA Neighborhood, for a liaison leader fee of $100 per year. I understand that the Firewise USA program itself is a volunteer program, free of charge.

 oSignature____________________________________________________________           Date _______________________

Fire Safe Community Liaison – Shelly Black (949) 697-8553    tcnoir93@gmail.com