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Firewood Application
Firewood Main Application
Client Name
(Required)
First
Last
Date
(Required)
Month
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Year
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone #1
(Required)
Phone #2
Referral Source
(Required)
List all adults and children in the home and their source for income
People in Household
Name
Relationship to Client
Age
Source for Income
Actions
Edit
Delete
There are no
Entries.
Add Entry
Maximum number of entries reached.
Family Situation/WHY does family need assistance?
(Required)
Please check all that apply
Elderly
Disabled
Limited Financial Resources
Single Parent
Family Illness
Job Loss
Other reason that prevents the person from obtaining firewood on their own
Please List Other Reason(s)
(Required)
Additional Notes re: Family Situation helpful for deliverers to know
House Type
(Required)
House
Trailer
Do you:
(Required)
Own Home and Land
Rent Lot
Rent Home and Lot
Home Ownership
Name on Deed
(Required)
First
Last
Square Footage
(Required)
Mortgage amount per month
(Required)
Land Ownership
Name on Deed
(Required)
First
Last
Number of acres
(Required)
Cost per month
(Required)
Renting Home
Cost per month
(Required)
Renting Lot
Cost per month
(Required)
Are there any local family or friends who can help unload the wood?
(Required)
Yes
No
Who and what relationship to the client?
(Required)
Is wood your only source of heat?
(Required)
Yes
No
Other Source of Heat
(Required)
How Have You Obtained Wood in the Past?
(Required)
Purchased
Family Provided
Donation
Cost $____/rick
(Required)
Do You Still Have That Resource?
(Required)
Yes
No
What Changed?
(Required)
How many ricks of wood do you use per month?
(Required)
Can a truck access where you store the wood?
(Required)
Yes
No
Can a truck and trailer?
(Required)
Yes
No
Are there any unseen areas in the yard to avoid?
(Required)
(i.e. septic tank, buried pipes, etc.)
Yes
No
Please list description of areas
(Required)
Consent
(Required)
CommunityWorx uses multiple volunteers to deliver wood. It will be the client's responsibility to inform deliverers at each delivery of any hazards to avoid in the yard. Please check the statement below to indicate your agreement of your responsibility for protection of your property and volunteers.
As the client, I accept responsibility to inform each volunteer delivering wood to my property of any hazards in my yard upon each delivery.
By when do you need wood?
(Required)
(Deliveries may not start until October 15th)
Now
1 Week
2 Weeks
Other
Completed By:
(Required)
First
Last
Date
(Required)
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Client Liability Release & Agreement for Firewood
1. Voluntary Participation:
I am requesting that CommunityWorx deliver donated firewood to my home and agree to allow volunteers to have trucks and/or trailers on my property for the delivery.
2. Agreement:
If there are physically capable residents at the home during the time of delivery, they will help volunteers unload and stack wood. Volunteers often are delivering after work and may not have time to stack wood.
3. Agreement:
The donated firewood is intended to be used in my home only for the benefit of heat for my family. I will not give the wood away or sell the wood. I understand that doing so will result in me no longer being eligible for services from CommunityWorx.
4. Agreement:
If there are any signs of illegal activity at the home, misuse of the wood for any purpose other than intended (indoor heat for the family), or for any other reason deemed necessary, I understand that CommunityWorx reserves the right to not leave a delivery of wood and/or discontinue services at any point.
5. Agreement:
If I move from my current address and cannot take the firewood with me or otherwise use it, I will contact CommunityWorx so that they may pick up the donated wood to make it available for other families in need.
6. Agreement:
I give permission for CommunityWorx to use pictures or video taken at my home for public relations and promotional purposes.
7. Agreement:
I understand that CommunityWorx is
not an emergency-based program
and that they rely on donations of firewood and volunteers to deliver it to make it available to families in need. If I am eligible to receive multiple loads of wood, I will call at least a week before needing it to get on the list.
8. Agreement:
CommunityWorx cannot guarantee the availability of firewood and cannot be the only source from whom I obtain firewood for the season. My plan to obtain wood from other sources includes:
9. Agreement:
So that CommunityWorx can serve as many families as possible, I agree to
not request wood more than needed.
I will call to
request wood no more than every 2 weeks.
I understand that I need to be conservative with using the wood since when the wood is out for the season, CommunityWorx has no other wood to provide.
10. Release:
Volunteers will be as careful as possible during the delivery, but I understand that accidents and unintended exposure to illness can happen. I understand that the following may occur, and I agree to hold CommunityWorx harmless for any damages including but not limited to the following:
I understand that trucks and trailers may cause damage in my yard, especially if the ground is wet.
I understand that it is
my responsibility to point out to volunteers upon each delivery any hazards in my yard that should be avoided
, such as the location of a septic tank.
I understand that contact with anyone leads to the possibility of exposure to illness. Due to the highly contagious nature of COVID-19 and its , even with use of recommended handwashing, facemasks, and distancing, it is impossible to fully eliminate the risk of exposure to illness. I will do my part to minimize exposure to COVID 19 and other illnesses by maintaining recommended guidelines for disease prevention at the time volunteers deliver.
In consideration of the opportunity to participate in CommunityWorx, I release CommunityWorx, its volunteers, and its partners from any liability suffered by my family, property, or myself during the delivery of firewood.
11. Knowing and Voluntary Execution:I have read this agreement and fully understand its contents. I am aware that this is a release of all liability and I sign it of my own free will.
Date
(Required)
Month
Day
Year
Location
(Required)
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Client's Name
(Required)
First
Last
Client's Signature
(Required)
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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