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Firewood Application
Firewood Application
Name
(Required)
First
Last
Date
(Required)
Month
1
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12
Day
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1922
1921
1920
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
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
Name
(Required)
First
Last
Relationship to Client
(Required)
Age
(Required)
Source for Income
(Required)
Social Security
Disability
Child Support
No Income
Retirement
Employment
Other
Retirement From Where?
(Required)
Retirement Amount
(Required)
Employment From Where?
(Required)
Hours Per Week
(Required)
Amount
(Required)
Please List Other
(Required)
Add Another Family Member?
(Required)
Yes
No
Name
(Required)
First
Last
Relationship to Client
(Required)
Age
(Required)
Source for Income
(Required)
Social Security
Disability
Child Support
No Income
Retirement
Employment
Other
Retirement From Where?
(Required)
Retirement Amount
(Required)
Employment From Where?
(Required)
Hours Per Week
(Required)
Amount
(Required)
Please List Other
(Required)
Add Another Family Member?
(Required)
Yes
No
Name
(Required)
First
Last
Relationship to Client
(Required)
Age
(Required)
Source for Income
(Required)
Social Security
Disability
Child Support
No Income
Retirement
Employment
Other
Retirement From Where?
(Required)
Amount
(Required)
Employment From Where?
(Required)
Hours Per Week
(Required)
Amount
(Required)
Please List Other
(Required)
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
(Required)
House Type
(Required)
House
Trailer
Do you:
(Required)
Own Home and Land
Rent Lot
Rent Home and Lot
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
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.
Please list description of areas
(Required)
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
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11
12
13
14
15
16
17
18
19
20
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24
25
26
27
28
29
30
31
Year
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
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