Safe and Healthy Homes Assessment Request by Ricky Hill | Nov 16, 2023 | Latest News Safe & Healthy Housing Assessment Request If you are providing a referral on behalf of someone else, please provide your contact information below. Be sure to notify the person of what you are doing so they are not surprised when we contact them. 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 Address Address City City State/Province State/Province Zip/Postal 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? * Frame house Brick house Mobile home Modular home Manufactured home 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 Are you a widow(er)? * Yes No Are you or is any member of your family (in the household) age 65 or older? * Yes No Signature signature keyboard Clear Using your mouse, you can draw your name or click on the keyboard icon and then type your name. If you are human, leave this field blank. Submit
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