Client application

DAY OF CARING 2012

CLIENT APPLICATION
Deadline for Applications is 3/30/12
To apply, a prospective client must meet all these criteria:

• 
  Live in Front Royal or Warren County
  
• 
  Total income at 150% or below the federal poverty guidelines (will need to submit documentation)
  
• 
  Own the home that needs work and be unable to do it
  

The kinds of jobs we are looking for are jobs that a team of volunteers could reasonably complete in a day. Some projects completed in the past include:

• 
  Painting
  
• 
  Clean-up
  
• 
  Yard work
  
• 
  Minor plumbing, electrical and carpentry work
  
• 
  Minor weatherization – windows, insulation
  
• 
  Tear-down of old decks, porches, etc.
  
• 
  Deck and railing repair/replacement
  
• 
  Landscaping/flower planting
  

NAME___________________________________________DATE___________________
ADDRESS_________________________________________________________________
TELEPHONE: Home_________________Cell________________________Email_________________________

EXPLAIN WHY YOU NEED ASSISTANCE FROM UNITED WAY: ______________


__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PLEASE DESCRIBE THE PROJECT(S) YOU NEED TO HAVE COMPLETED. (If more than one, please list in priority order. Attach sheet if there are more projects)
1).____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2). ___________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3). ___________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________

What is your total annual income? ______________________ (Attach latest Income Tax Form)
Do you qualify/receive state or federal assistance? Identify type and amount. (Medicaid, food stamps, etc). __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How many individuals live at this location? _______What are their ages? _____________________________
How will this assistance help you or improve your quality of life? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Other comments________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please return to:

United Way of Front Royal/Warren County

P. O. Box 509

Front Royal, VA 22630

540-635-3636

Deadline for Applications is 3/30/12

UNITED WAY

DAY OF CARING

Client Waiver Statement

(All clients must sign a copy of this form before any work is completed).
LIABILITY DISCLAIMER: In accordance with the spirit of volunteerism and service, I, the undersigned, I release full and complete responsibility for any injury or accident that may occur during my voluntary participation during the year 2011 Day of Caring activities. Therefore, I hereby release, indemnify, and hold harmless Front Royal/Warren County United Way, the organizers, the agency or project site at which volunteers and sponsors and supervisors of all activities from any and all liability in connection with any injury (including any injury caused by negligence), or physical damage to my residence, in conjunction with volunteer activity held during participation during the year 2011, the specific date to be determined between the project recipient and the volunteer work team. I acknowledge that there are certain foreseeable and unforeseeable risks associated with participating in this event, including, but not limited to, illness, and the effects of the weather, all such risks being understood and appreciated by me.
COMMUNICATIONS RELEASE: I hereby assign the rights for the video and /or photographic recording(s) made of me during participation in a volunteer activity by United Way or its agencies. I hereby authorize the editing, duplication, reproduction, copyright, exhibition, broadcast and or nonprofit use and distribution of said recordings for purposes deemed suitable by United Way.
I hereby waive any right to approve the finished products.
I certify that I am over eighteen years of age and am competent to enter in to this release.
I have read the foregoing releases, authorizations, and agreements, before affixing my signature below and warrant that I fully understand their contents.
Signature: Date:
Name and Address (please print): ____________________

Phone: Email: _______________

Please return to:

Front Royal/Warren County United Way, Inc.

P. O. Box 509

Front Royal, VA 22630

540-635-3636

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