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Paint-a-thon
Paint-a-thon Homeowner Form
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Heat's On
Paint-a-thon Homeowner Form
in
Paint-a-thon
Homeowner Name:
*
Age:
*
Other Household Members
Name (2):
Age (2):
Name (3):
Age (3):
Name (4):
Age (4):
Name (5):
Age (5):
Contact Info
Address:
*
City:
*
State:
*
Zip Code:
*
Daytime Phone:
*
Evening Phone:
Best Time To Contact:
e-Mail:
Have you received any Project Home Services?:
*
Yes
No
If so, select those you've received::
*
Major or Minor Home Repair
Hammer with a Heart
Paint-a-thon
Weatherization
Home Information
Number of Stories:
*
One story
One and a half stories
Two story
Areas that need painting:
*
Window & Door Trim
Entire House
Attached Garage
Detached Garage
Porch or ramp
The exterior of my home is:
*
Wood Siding
Brick or Stone
Stucco
Aluminum or Vinyl Siding
Other
Event Information
Volunteers will need to be inside your home during the day's events. Can the volunteers use the bathroom facilities in your home:
*
Yes
No
Can you provide refreshments during the day for volunteers? (water, soda, etc.):
*
Yes
No
Can you supply equipment for the paint day? (ladders, paintbrushes, rags, etc.):
*
Yes
No
If yes, what supplies do you have available?:
Can you or your family help with clean up?:
*
Yes
No
Household Income
Please fill out all income received by your household. You will be asked to provide verification of this income during the selection process. “Income” means any amount received from the following sources by all household members. Please be prepared to include income documentation (pay stubs, social security letter etc…) and all monthly income by category listed below or your application will not be complete:
Interest and Dividends:
$
annually
Child Support:
$
annually
Business Profit:
$
annually
Pensions & Annuities:
$
annually
Rental Income:
$
annually
Social Security:
$
annually
Salaries:
$
annually
Any Public Assistance:
$
annually
Estate or Trust Income:
$
annually
Total Income:
*
$
annually
Disabilities
Are you or anyone in your household disabled?:
*
Yes
No
If so, who?:
What is the nature of the disability?:
Photographs/Interviews:
Yes
No
To solicit volunteers and funds for Hammer with a Heart, it is essential that Project Home publicize this event. Are you willing to be photographed and interviewed regarding your involvement with Hammer with a Heart.
How did you hear about this program?:
*
Ethnic Background:
Black
American Indian
Hispanic
Asian
White
Please check the category that represents your ethnic background? (Response to this question is optional)
Please type your full name:
*
By signing below, I recognize that in consideration of my voluntary participation in the Dane County Paint-a-thon, which is a charitable event, I agree to release all sponsoring organizations (including their officers, employees, members, and agents, all other volunteers, and homeowner participants) from all liability whatsoever which may arise out of or be connected with participation in this event and all activities related to it. I certify that I am the current owner of this home and, as such, I am not presently planning to, nor do I intend to within the next two years, sell my home. I understand and agree to have my home painted by volunteers. I, the undersigned, certify subject to disqualification, that this information is true and correct to the best of my knowledge and belief, and that the provisions stated are accepted and agreed to.
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