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2. First Name*
3. Last Name*
5. Address*
7. City
8. State
9. Zip Code
11. Phone Number*
12. Email Address
14. Your Age
15. Number of people living in your house*
17. Are you currently receiving Social Security for age or disability?*

    1. Yes
    2. No
19. Please provide a description of cleanup assistance you need.*

    This program will use volunteers to assist with the work. Please provide photos below so we can determine if it's something which volunteers are capable of assisting.

21. Please upload photos of tree damage/cleanup needed if possible.
23. Image 1
24. Image 2
25. Image 3
26. Image 4
28. Additional Information May Be Required

    Please note, prior to receiving assistance through the Neighbors Helping Neighbors program, the applicant will be required to sign a certification verifying that you agree to the terms and conditions of the program, as well as a liability waiver. This form is available on our website and can be uploaded as part of this online application. It can also be emailed to wholtkamp@roelandpark.org or found at City Hall. 

30. Applicant Certification and Home Owner's Agreement and Release from Liability
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field