Project Referral Form

Name of Host

(Include husband and wife's names and ages if applicable)
Phone
Address
Street Address Address Line 2 City State ZIP Code

(Be sure to include a unit # if applicable)
Need(s)
- Flooring
- Walls
- Plumbing
- Door(s)
- Electrical
- Roof
- Wheelchair ramp, porch, steps
- other
What needs do you have that are unsafe in you home?
Best Phone # for contact
Owner of home
Owner's birthday
MM slash DD slash YYYY
Owner's age
Relationship Status
Source of Income
How many people live in your home besides you?
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
List any serious medical issues or disabilities with members of this household?
Do you have a Home Church?
Name of Church
Pastor's Name
Have you received help from another ministry?
Name of Organization
Year help was received
List family members who can help with your needed project?

(Name and relationship)
This Section for Ministry Representative
(Have the ministry representative fill this out if they assisted with the referral form.)
Date of contact?
MM slash DD slash YYYY
Date of home visit?
MM slash DD slash YYYY
Who referenced the home owners?
Site Visit
Name of Representative who helped fill out this form?
Phone
Restoration Information
Project Type
- Jerusalem Project
- Individual Project
Number of Volunteers?
Please enter a number greater than or equal to 0.
Project Leader
Phone
Email
Photos Taken?
- Yes
- No
Site Leader
Phone
Email
Photos Taken?
- Yes
- No
Leader Skills Needed
Check every area of need the home owner has mentioned
- Wheelchair Ramp
- Porch/Steps Flooring
- Wall Board
- Inside Painting
- Plumbing Kitchen
- Plumbing Bathroom
- Front Door Repair
- Interior Door
- Electrical Work
- Interior Ceiling Repair
- Outside Roof Repair
- Outside Painting
- Siding Repair
- Window Repair
- Screen Repair
- Yard Work
Other Areas of Need
Specific Room Photo
Max. file size: 50 MB.
Work Needed?
Specific Room Photo
Max. file size: 50 MB.
Work Needed?
Specific Room Photo
Max. file size: 50 MB.
Work Needed?
Specific Room Photo
Max. file size: 50 MB.
Work Needed?
Specific Room Photo
Max. file size: 50 MB.
Work Needed?
Additional Information
Review After Work Day
Name of Site Reviewer
Phone
Date
DD slash MM slash YYYY
More Work to be Done?
- Yes
- No
How quickly is the need?
Agreement

I understand that by filling out this form, The Way 2 Serve ministries is not agreeing to repair my home. I am aware that the Way 2 Serve Ministries will contact me to inform me whether or not they will be able to assist.
Do you agree to the agreement?*
- Yes
- No
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Project Referral Form

This Section for Ministry Representative

Restoration Information

Review After Work Day

Agreement