Please fill out the application completely, and return it to: A Brush With Kindness Program, 524 Main Street, New Rochelle, NY 10801 Name of Homeowner(s)____________________________________________________________ Address: ________________________________________________________________________ City: _________________________________________State:_______ Zip Code:_______________ Phone Number(s): Home: ___________________________ Work: __________________________ List all others living at this address and their ages: Name: ___________________________________________________________ Age: ___________ Name: ___________________________________________________________Age: ____________ Name: ___________________________________________________________ Age: ___________ Name: ___________________________________________________________ Age: ___________ It is important that our volunteers have use of bathroom facilities. Will your bathroom facilities be available to volunteers? Yes______ No _____ If your home is chosen, will you be willing to be interviewed or have your picture taken by the media? Yes_____ No _____ Sign name for approval: _____________________________________________________________ HOUSE INFORMATION: Circle the size of your home: 1 story 1.5 story 2 story 2.5 story 3 story Type of material on house (wood, stucco, aluminum, brick, shakes, etc.) House Siding __________________________ Trim _________________________ Garage Siding _________________________ Trim _________________________ Circle parts of home that need painting: Check garage size: House Siding 1 stall __________ Garage Siding 2 stall __________ House Trim 3 stall __________ Garage Trim no garage _______ Other - Fence / Deck / Shed __________________________________________________________ Please list and describe all other outside work that you would like done (except roof repair): _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Does anyone in your home have special needs? Please describe: ___________________________________________________________________ _________________________________________________________________________________ Are there any other special family circumstances we should consider? _________________________________________________________________________________ Please indicate the income of all persons living in the home. Combined annual income from salaries, public assistance, pension, social security, rental income, etc all info confidential__________________________________________________________________ Please list all the adults living in your house. I accept and agree to the stated provisions of this program and release A Brush With Kindness, Habitat For Humanity of Westchester, Inc., and all associated with it from any and all liability. _______________________________________________ ______________________ Homeowner Signature Date All potential homes must be tested for the presence of lead based paint. One of our staff will perform a minor test when they inspect your home. Please sign below to give your approval for this test. ________________________________________________ ______________________ Homeowner Signature DateHOMEOWNER INFORMATION
PARTNERSHIP WITH “A BRUSH WITH KINDNESS”
SPECIAL NEEDS/ pumping out water/ debris removal etc....
INCOME INFORMATION
HOMEOWNER AGREEMENT: I certify that the information on this application is correct to the best of my knowledge. I have no plans of moving or selling my property in the next two years. I confirm that my home is a safe place for volunteers to work. I understand that all physically able persons living in my home or visiting during the time that volunteers are working on my home will be expected to work alongside A Brush With Kindness volunteers. I also understand that the people who work on my home are volunteers and that A Brush With Kindness makes no warranties, expressed or implied, regarding any materials used or work done by anyone at my house.