<form-template> <fields> <field type="select" required="true" label="Have you met with an Outreach or Recovery Worker regarding the impact of the 2024 fire?" description="This includes an intake by phone or in person. The intake does not have to have taken place in Jasper. " class="form-control select" name="select-1758640265026"> <option selected="true">Yes</option> <option value="option-2">No</option> </field> <field type="text" subtype="text" required="true" label="First and last name: " description="Enter your name: First Name, Last Name" class="form-control text-input" name="text-1758639901649"></field> <field type="text" subtype="text" required="true" label="Phone number: " class="form-control text-input" name="text-1758639963855"></field> <field type="text" subtype="text" required="true" label="e-mail: " class="form-control text-input" name="text-1758639948136"></field> <field type="text" subtype="text" required="true" label="Current physical address:" description="If displaced outside of Jasper by the 2024 fire, please enter your current physical address including town/city and province.. " class="form-control text-input" name="text-1758640713325"></field> <field type="select" required="true" label="Please indicate the types of challenges you are facing at this time that are related to the 2024 fire:" description="You can select more than one! Hold the CTRL key and pick all that apply. " class="form-control select" name="select-1758640845777" multiple="true"> <option value="option-2">Transportation </option> <option>Winter clothing or supplies</option> <option value="option-1" selected="true">Food</option> <option>Infant supplies</option> <option>Replacing household items</option> <option>I am behind on my rent</option> <option>Utility arrears</option> <option>Pet supplies</option> <option>Accessing sports or recreation </option> <option>Childcare</option> <option>Navigating re-build of my home</option> <option>Medication or medical appointments</option> <option>Mental health challenges</option> </field> <field type="text" subtype="text" label="Please use this field if you would like to tell us more about what challenges you are facing related to the 2024 fire. " class="form-control text-input" name="text-1758641653947"></field> <field type="select" required="true" label="Have you received funding via electronic funds transfer (EFT) from the banff canmore foundation on behalf of the municipality of Jasper? " class="form-control select" name="select-1758641585036"> <option value="option-1" selected="true">Yes</option> <option value="option-2">No</option> </field> <field type="select" label="If you said yes to the question above, has your banking information changed in the past six months? " class="form-control select" name="select-1758641466979"> <option value="option-1" selected="true">No, my information has not changed. </option> <option value="option-2">Yes, my banking information has changed. </option> </field> <field type="text" subtype="text" required="true" label="I certify that the information in this form is correct. I know my information will be shared with Community Outreach Services to support recovery from the 2024 wildfire. I give permission to Community Outreach Services to call or email me using the details provided to clarify anything. Please write your name in the space below in place of a signature: " class="form-control text-input" name="text-1758641729551"></field> </fields> </form-template> Submit Submitting...
