Safe and Healthy Home Assessment

24Jan

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

 

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.
Format: mm/dd/yyyy
Address *
Address
City
State/Province
Zip/Postal
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.