2019 Clarence-Rockland Flood Recovery Assistance Request

Request Date: *
Name:*
Address:*
Neighbourhood:
Postal code:*
Phone: *
Work phone:
Mobile phone:
Email:*
Structure type:*
Home Occupied:*
Home accessible:*
Details:

The NGO Alliance of Ontario, Team Rubicon Canada and the City of Clarence-Rockland respect the information provided by the signatory of this form. The NGO Alliance of Ontario, Team Rubicon Canada and the City of Clarence-Rockland will take the necessary steps to only collect the information necessary to offer the assistance agreed upon and will ensure your information remains confidential and will only be used for the purposes it is intended for.

In order to serve you better, by checking the box you acknowledge that information collected by The NGO Alliance of Ontario, Team Rubicon Canada and the City of Clarence-Rockland members for purposes of flood assessment, recovery and remediation will be placed into a public domain application for geo-mapping, coordination and priority-setting purposes and that permission has been given to Team Rubicon Canada for this to be done.

I understand and consent to the conditions outlined above.*

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