Family Information: Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred Form of Contact *

Call

Text

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)

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

Yes

No

Arrangements can be made depending on service date.

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

I have access to running water on the exterior.

I have access to electricity on the exterior.

Volunteers may use the restroom at my residence.

I have space for vehicle parking for vans.

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 +

Veteran *

Are you a veteran of the US Military

Yes

No

Gender *

Male

Female

Non-Binary