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3224 Bee Ridge Road, Sarasota, FL 34239 - Phone: 941-924-1323 - Fax: 941 923-9594

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Church of the Palms Emergency Survey Form

If you need help with this form contact the church, 924-1323 and give them your name so a volunteer can call to help you!

This survey form should be completed and submitted for the EPC (Emergency Preparedness Committee). The information included will be confidential and utilized only in the need for an evacuation or in response to an emergency or disaster.

For a printable form click here to download, complete and drop off at the church.

Church of the Palms Home Page

Emergency Survey Form

Number in family:
Cell Phone #1:
Cell Phone #2:


Zip Code:
Name of Community/Development:

Do you have a family plan in the event of an emergency or mandatory evacuation :

Yes No
(If "no" then please consult emergency information and make your family unity plan.)
The Special Needs Questionnaire is used to form a confidential listing by Sarasota County that is maintained on an annual basis of people who need assistance due to their physical or medical condition and have no other alternative for safe shelter.
Do you need help from the County?
Have you registered with the county for special needs sheltering?
(If "no" do you need help filling out the Special Needs Questionnaire?
Do you live in Manatee County?
Are you dependent on emergency support equipment?

Yes No
Yes No
Yes No
Yes No
Yes No

If Church of the Palms is asked about your welfare after an emergency, do you have a contact person, family/friend, outside the affected area?

Yes No

If "yes" please list a contact person outside immediate area :
Contact Name
Contact Relationship
Contact Phone:
Contact Address:


Zip Code:
Would you accept church families who may be required to evacuate from the beaches and low lying areas?
Yes No
In the event of a maninland disaster not affecting beach areas, will you accept church families who may be in need?
Yes No
Please indicate your residence:
Are you a smoker?
Yes No
If needed, how many can you house temporarily?
Will you accept pets?
Yes No
Dogs Cats
Are there any restrictions?
Please List
Would you be willing to volunteer for a Church of the Palms Emergency Preparedness Action Response Team
Yes No
Do you have special equipments, which can be used if necessary, such as a truck, generator, chain saw, pump
Please identify:
Are you a HAM operator?
Would you help with communications?
Would you help Church of the Palms?
Sarasota County HAM Ops. Group?

Please Note: The COP Emergency Preparedness Program does not replace emergency services provided by the County emergency teams, Red Cross, Salvation Army, FEMA, etc. However, the COP Emergency Preparedness Program is concerned about your welfare and your personal concerns. We are concerned about our church property and the community. We love and care about you.

You may submit this form or download, print out and complete a hard copy then drop it off at the Church Office or at the Information Center under the Fellowship Tree on Sundays. More information is available at the Information Center.


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