Form Center

2. Code Blue Emergency Shelter Questionnaire
   In these unprecedented times, we are critically concerned about residents faced with homelessness following an eviction or foreclosure. We are especially concerned when temperatures drop below freezing and we enter into a Code Blue scenario. If your organization is interested in becoming a Code Blue Emergency Shelter, please complete the fields below.
4. Organization Name*
6. Organization's Address*
8. City*
9. State*
10. Zip*
12. 24-hour Phone Number*
13. 24-hour Point of Contact*
15. Facility Information
17. Number of beds*
19. Bedding*

    1. Yes
    2. No
20. Washroom/Toilet*

    1. Yes
    2. No
21. Showers (if applicable)*

    1. Yes
    2. No
22. Meals*

    1. Yes
    2. No
24. Would you be willing to make your space available for an outside contractor to run the shelter? *

    1. Yes
    2. No
26. Set-up for:*

    1. Families
    2. Men Only
    3. Women Only
27. Pets?*

    1. Yes
    2. No
28. Parking?*

    1. Yes
    2. No
29. How many vehicles?
31. Veteran Community Preference? *

    1. Yes
    2. No

    The veteran community includes veterans and family, including adults, children, and spouses.
33. Can you comply with CDC guidelines for Cleanliness and Social Distancing? *

    1. Yes
    2. No
35. Will you have an overnight presence for safety and security?*

    1. Yes
    2. No
37. Disclaimer
    The County of Montgomery makes no representations or warranties as to the suitability of this information for your particular purpose, and that to the extent you use or implement this information in your own setting, you do so at your own risk. In no event will the County of Montgomery be liable for any damages whatsoever, whether direct, consequential, incidental, special, or claim for attorney fees, arising out of the use of the information you have provided. As a Code Blue Emergency shelter you accept all liability and responsibility for the safety and security of the person you are providing services and hold harmless the County of Montgomery. Additionally you agree to comply with CDC Guidelines found at https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/plan-prepare-respond.html.
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field