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 Safer From Wildfires 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 Agent who is seeking to assist California residents in becoming Certified in Safer From Wildfires programs.  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.

I understand that Safer From Wildfires is a volunteer program, and Shelly Black, as an Independent Agent has a membership fee of $100 for the first year, and $50.00 annually thereafter, for her Fire Safe Community Program.

Signature ___________________________________________________           Date _______________________

Neighbor who referred me is:  ______________________________________________________

Fire Safe Community Agent – Shelly Black 

  www.FireSafeCommunity.com      tcnoir93@gmail.com