Family Information: Name *

First Name

Last Name

Phone *

(###)

###

####

What is the preferred form of communication? *

Text

Call

Email

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Requested *

Please check all that apply. If more than one project is needed, please prioritize in the comments section below. We do not do plumbing, electrical work, roof repair, or flooring. Due to time and budget, we typically cannot accept ramps larger than 30 feet and porches larger than 5x5. If you have questions about your specific project request, please contact referral@carolinacrossconnection.org.

Wheelchair Ramp

Porch

Steps

Yardwork

Minor Exterior Painting (porch stain, some trim, etc)

Tell us more about the residence (check all that apply) *

There is exterior access to running water.

There is exterior access to electricity.

There are restrooms available to volunteers.

There is parking available for vans.

Would someone from the household be on site while volunteers are working? *

Yes

No

Arrangements can be made depending on service date.

Race/Ethnicity *

Native American/American Indian/Indigenous

African American/Black/African

Hispanic/Latino/Latina/Latinx

Caucasian/White/European

Asian/Asian American/Pacific Islander

Multi-Racial/Multi-Ethnic

Other

Age *

Under 35

35-50

51-65

Over 65

Income *

Household Less than $25,000

Household $25,000-$45,000

Household $45,000 +

Gender *

Male

Female

Non-Binary

Contact Name *

First Name

Last Name

Contact Phone *

(###)

###

####

Should we contact you before contacting the family?

Yes

No