Disaster Relief January 2025 Intake Form

We’re working around-the-clock to provide support and connect our SEIU 721 members with disaster relief if they need it.

In addition, we are gathering information to make an assessment of the impacts on our members. Click on the button below to submit your information.

First Name*

Last Name*

Employee # (If you do not know your employee #, please enter 0000)

Cellphone ***

Home Zip Code*

Personal Email*

Member?*

Yes
No

Steward/Leader?*

Yes
No

Have you been adversely affected by the 2025 LA County wildfire?*

Yes
No

If YES, please continue below.

DUE TO THE WILDFIRES, YOU HAVE EXPERIENCED:

Total loss of home?

Yes
No

Major destruction of home making it uninhabitable?

Yes
No

Total number of family members in the home:

Are their children under the age of 18 in the home?

Yes
No

If YES, how many?

Other family members who require special assistance in the home?

Yes
No

If YES, how many?

Are you concerned about falling into homelessness?

Yes
No

Loss of transportation?

Yes
No

Physical injury?

Yes
No

Employer:*

Department:*

Job title:*

**By providing my phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. To unsubscribe, text STOP at 721721. For info, text HELP at 721721.

Name

This field is for validation purposes and should be left unchanged.

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