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Disaster Relief Request Form

Hurricane season has begun. Ruth & Norman Rales Jewish Family Services ("JFS") is prepared to assist you once a hurricane or tropical storm has passed.

Please fill out and submit this form if you would like JFS to call you and check in on you before and after a storm. Once it has been determined that it is safe to be on the roads, JFS may deploy volunteers to your home to check on you and/or bring you supplies if needed.

(Contact 911 in case of an immediate emergency)

Your Information

Email*

First Name*

Last Name*

Address*

City*

ZIP Code*

Phone*

Second Phone

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Email

Do you have Internet & Email access?

If you are a current JFS client, who is your JFS staff contact?:

Your Age

Gender Identity

Total number of members in your household?

Do any members of your household have a disability or require special assistance? If so, explain

Comments or Questions

* Required information

Jewish Federation of South Palm Beach County

NJHSA

PBCCS

Dept.ElderAffairs_FL

AreaAgencyAging

Nonprofits First

United Way PBC

Children's Services Council of Palm Beach County

Claimscon

JFNA

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Contributions benefit Ruth & Norman Rales Jewish Family Services, Inc., a not-for-profit, tax-exempt organization. A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES AT www.FloridaConsumerHelp.com OR BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. Registration #CH13203