Friends in Faith Serving Emporia, Revitalizing Church and Community. Eswin Rios, FFSE Coordinator. Friends in Faith Serving Emporia
Eswin Rios, FFSE Coordinator
517 Merchant Street, Suite 201 | Emporia KS 66801 | 620.342.8100

Web Site Sponsor:Lyon-Coffey Electric Co-op
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Assistance Resources Questionnaire

Please complete this questionnaire to help us understand the assistance resources available through your organization or you. Click "Submit" at the bottom of the form to forward your information to Friends in Faith Serving Emporia. You must have an e-mail address that allows this form to be sent when Submit is clicked. Free Hotmail accounts will not forward this form.

Today's Date mm/dd/yy

Organization Information
Name of Organization
Organization Type Faith-based Business Individual
Contact Person
Title
Street Address
City, ST ZIP Code
Office Phone 999-999-9999
Fax 999-999-9999
Other Phone 999-999-9999
E-mail address
Web Site Address


Contact for Area-wide Emergency Communication
This contact information will be compiled and used for emergency response and assistance. The Emporia City Manager is currently the lead agency for coordinating efforts and the available resources will be communicated to that office. The City Manager can then request these resources and Friends in Faith will relay the request to the appropriate church/organization.

In the event that a needed resource is not in the database, a request will be sent to everyone. Friends in Faith Serving Emporia will keep the emergency contact informed about the current status of work being done in the community.

Coordinator/Emergency Contact
Coordinator Street Address
Coordinator City, State ZIP
Coordinator E-mail
Coordinator Phone 999-999-9999
Coordinator Fax 999-999-9999
Coordinator Cell Phone 999-999-9999
Is it ok to send text messages to your cell phone in urgent situations? Yes
IM AIM ID
IM Yahoo ID
IM MSN ID

You/Your Organization Can Provide...
Please check all that apply.

Personal counseling
Group counseling
Mentoring for financial planning
Assistance with preparation of taxes
Mentor for job hunting (resume, searching, filling out applications)
Mentors to help people understand available resources
Computers w/printer & Internet access (at your location)
Number of computers
Can provide van transportation
How many passengers?
Have people to drive van
Provide building space for community gatherings
Building Space Fees? Yes No
Building space description
Sq. ft., location, kitchen area, seating capability, etc.
Child care services/provider
Childcare fees Yes No

You/Your Organization would like to volunteer to...
Assist with community gatherings.
Provide pastoral care at community gatherings.
Help collect information about displaced workers.
Help people move/relocate to other cities.
Provide emergency housing.
Volunteer at Abundant Harvest Soup Kitchen.
Package/distribute food for Salvation Army.

You/Your Organization can help with Food Assistance
Cash Gift Card Canned
Frozen Refrigerated Formula
Diapers Milk/Juice Dry goods/Breads
Other Food Assistance Description

You/Your Organization can help with Other Assistance
Gas/Diesel
Utilities
Rent or Mortgage
Provide a gathering place for displaced workers
Make a contribution to LCREF
Lyon County Restricted Emergency Fund.
Make a contribution to FFSE
Friends in Faith Serving Emporia.
Other Assistance Description

Please tell us if your organization or denomination has an organized way of responding and how they might be able to help if called upon.

Thank you for your time and contributions!

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