I (we) certify that the information provided in this application is true, correct, and complete to the best of my (our) knowledge. I (we) understand that failure to provide complete information may result in the termination of assistance through Project Mend-A-House. By my (our) signature(s) below, I (we) also authorize the sponsors of Project Mend-A-House to assess, organize, and coordinate repairs to my (our) home that I (we) have requested. I (we) understand that this request can only be honored if appropriate volunteer assistance, materials, and resources are recruited and received by Project Mend-A-House and the request receives approval of the Project Mend-A-House committee. I (we) hereby agree that I (we) will not use Project Mend-A-House’s resources (labor and materials) to make improvements on my (our) home so that I (we) may sell the property within the year of completion. If my (our) property is sold prior to one year after the repair completion date, I agree to reimburse Project Mend-A-House the cost of the materials and $25 per labor hour.
I (we) hereby release and agree to hold harmless Project Mend-A-House, its staff, and volunteers from any liability in connection with the performance of home repairs and improvements, accidental damages to property, subsequent personal injuries resulting from the use of the repaired facilities, or failure of materials used for home repairs. Further I (we) will help others learn about Project Mend-A-House and I (we) agree to the use by Project Mend-A-House of photographs, slides, and media articles of the repair to publicize the benefits derived from this program.
I (we) understand that different agencies provide different services and benefits. Each agency must have specific information to provide services and benefits. By signing this form, I allow agencies to use and exchange certain information about me, including information in an electronic database, so it could be easier for them to work together efficiently to or coordinate these services or benefits. I authorize PMAH to share my contact information to the Area Agencies on Aging and No Wrong Door/Senior Navigator.
For, and in consideration of, Project Mend-A-House, I, the undersigned, for myself, my heirs, successors and assigns, agree to release and forever discharge Project Mend-A-House, their officers, employees, and agents from any and all liabilities, demands or claims for loss or damage resulting from any injury or damage which may be sustained on account of using equipment from the Loan Closet, Freedom Alert or Fan Care Programs.
