Safe and Healthy Homes Assessment Request

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First Name *

Last Name *

Date of Birth

Format: mm/dd/yyyy

Address *

Address

City

State/Province

Zip/Postal

Email

Phone *

Do you send/receive text messages? *

Yes

No

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

Text

Call

Email

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

What concerns do you have? Please select from the list below:

You may check more than one concern.

What type of dwelling do you live in? *

Do you own this home?

Yes

No

Additional projects may be determined by Hinton and volunteers. If we’re working at a home, other projects may include: yardwork, cleanout/ trash removal, basic gutter cleaning (not installation), gardening, window/general cleaning, replacement of light bulbs/ smoke detectors, other small projects, as able.

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

Number of persons living in the house who are 19-64? *

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

Number of persons living in the house who are 65+? *

Please list any special circumstances regarding your application? *

How did you hear about Hinton Center? *

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

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There are no financial guidelines or requirements for having a Safe & Healthy Housing check done at your home. Homeowners and renters may apply for the home check.  However, in order for Hinton to make repairs to your home, there must be financial need or extenuating circumstances.  
Once you submit a Safe and Healthy Homes Assessment Request form, Hinton Center will be in touch to schedule a time to visit your home. It may take time for us to come to do the assessment. You may contact us to check the status at 828-389-8336 or missions@hintoncenter.org.  
Hinton Center partners with the community to improve the health and safety of homes.  
Our volunteer groups are not professionals.  
Submitting a referral form or having a safe and healthy homes check does not guarantee that Hinton will be able to make needed repairs.  
While Hinton is at your home, we may take pictures that could be used to promote the mission of Hinton Center. 
Please notify Hinton Center if there’s any change with your contact information.  
HINTON CENTER COMPLETES THE FOLLOWING PROJECTS: accessibility ramps, porch and exterior stair repair/ rebuild /construction, handrails, underpinning, staining, general painting (interior and exterior – one story homes),  grab bars, firewood storage lean-to’s, screen replacement, doors, carpet removal and basic flooring (generally not subflooring), firewood removal, and other projects as determined by Hinton and volunteers.  If we’re working at a home, other projects may include: yardwork, cleanout/ trash removal, basic gutter cleaning, gardening, window/general cleaning, replacement of light bulbs/ smoke detectors, other small projects, as able. 
Our work is done by volunteers. It may take a while for us to be able to return to your home. The majority of our groups come in the months of June and July.  
If the repairs are NOT within the scope of the work we are able to complete, we will do our best to help refer you to other resources.  Hinton does NOT do the following types of repairs: roofing, well repair/installation, septic work, foundation work, bathroom renovation, electrical, subflooring, window replacement, downing trees. (If you are a veteran, please call us at 828-389-8336 to inquire about potential grants that may cover these kinds of projects.) 
After receiving the safe and healthy home check, Hinton may contact you for follow up questions. Much of our funding is from grants, and we appreciate your participation so that we are able to complete reports and help more people in our community.  
 If the repairs are in the scope of the work we are able to complete, please note that to qualify for home repair assistance from Hinton Center…  
The person should own (not rent) the home / property.  It has to be a safe working environment for our groups. 
There must be financial need (or extenuating circumstances).  
Our construction coordinator and committee reviews applications and selects appropriate worksites based upon specific criteria, and the skills and preferences of the registered volunteer groups.  
The Hinton Center generally makes repairs in an area of a one-hour drive time radius of Hayesville, North Carolina, within Clay and Cherokee counties (NC) and Towns (GA).
If repairs are to be made to my home, I agree to and understand the following:  
I understand that everything requested may not be done to my home.  
I agree to have someone present at my home while the work is being done, unless prior arrangements have been made with Hinton Center staff.  
I understand that Hinton Center uses volunteers to complete the work and not professionals.  
I understand that sometimes a Hinton Center group may start a project but because of uncontrollable circumstances may not be able to finish. I also understand that Hinton Center will try to have agreed upon work finished if at all possible.  
I understand and agree that restroom facilities will be made available by me in my home for the work group members while they’re on-site, unless other arrangements have been made with Hinton Center staff.  
I understand that any used project materials are the property of the Hinton Center and will not be left at my house, except for some paints and stains. 
I understand that pictures may be taken at my home by the Hinton Center / work teams and may be used to promote the mission of Hinton Center.   
I understand that if contact information (including my phone number changes), I’m responsible for informing Hinton Center staff. Call 828-389-8336 or email missions@hintoncenter.org.

Referred by: First Name

Referred by: Last Name

Referred by: Phone Number

Referred by: Email

I have read and agree to the information above.

Yes

No

Signature

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HINTON RURAL LIFE CENTER

Safe and Healthy Homes Assessment Request

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