Safe and Healthy Homes Assessment Request

Referred by: First Name

Referred by: Last Name

Referred by: Phone Number

Referred by: Email

First Name *

Last Name *

Date of Birth

Format: mm/dd/yyyy

Address *

Address

City

State/Province

Zip/Postal

Email

Home Phone *

Mobile Phone *

Do you send/receive text messages? *

Yes

No

What is the best way to reach you? Check all that apply.

Text

Call cell

Call home

Email

Are you able to provide any materials or funding towards the repairs? Please explain: *

What about your home concerns you most? *

(Examples: wabbly railing, lack of working smoke detectors, problems with mold/mildew, concerns about your water, etc.)

What type of dwelling to you live in? *

Do you own this home?

Yes

No

What is the total number of people who live in the home? *

Number of persons living in the house who are 18 or older? *

Number of persons living in the house who are under 18? *

Please list any special circumstances regarding your application? *

How did you hear about Hinton Center? *

Hinton Center appreciates our local volunteers. Would you like to give back? If so, our volunteer coordinator will contact you. *

Yes

No

Are you or is any member of your family (in the household) a veteran? *

Yes

No

Are you or is any member of your family disabled? *

Yes

No

Prefer not to answer

Are you a widow(er)? *

Yes

No

Prefer not to answer

Are you or is any member of your family (in the household) age 65 or older? *

Yes

No

Prefer not to answer

Signature

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Using your mouse, you can draw your name or click on the keyboard icon and then type your name.

HINTON RURAL LIFE CENTER

Safe and Healthy Homes Assessment Request

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