Safe and Healthy Home Assessment

24Jan

2020 Safe & Healthy Housing Assessment Request
HINTON CENTER, PO BOX 27, HAYESVILLE, NC 28904.

 

2020 Safe & Healthy Housing Assessment Request
First name, Middle initial, Last Name
Format: mm/dd/yyyy
Address *
Address
City
State/Province
Zip/Postal
Country
Do you send/receive text messages? *
(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? *
Hinton Center appreciates our local volunteers. Would you like to give back? If so, our volunteer coordinator will contact you. *
Are you or is any member of your family (in the household) a veteran? *
Are you or is any member of your family disabled? *
Are you a widow(er)? *
Are you or is any member of your family (in the household) age 65 or older? *
Using your mouse, you can draw your name or click on the keyboard icon and then type your name.
Scroll Up