KEEP YORK COUNTY WARM!
Weatherization Program Registration Form
The goal of Keep York County Warm! is to bring together teams of community volunteers to help sponsor and install weatherization materials in low-income households or households with disabled homeowners.
List of Homeowner Requirements:
Step 1: Be available for one home assessment day and one installation day
Step 2: Obtain Referral
Step 3: Sign a Homeowner Agreement Form (to be signed on assessment day)
Step 1: Be available for one home assessment day and one installation day (check the boxes to confirm)
¨ I will be available for a home assessment day (One day in April)
¨ I will be available for an installation day (One day in May)
Step 2: Obtain a Referral: Please obtain a signature for the referral statement below. The signature must be from a General Assistance officer, outreach worker, code officer, health officer, church leader, or the Southern Maine Agency on Aging.
Please read the following statement, then sign and date the form (to be done by referring agency).
I certify that the homeowner whose information I am providing to you meets the above requirements, and has signed a Waiver of Confidentiality to receive help from the Keep York County Warm program.
As a ______(job title), I refer ______to the program. (Name of Homeowner)
______
(Signature) (Date)
______
(Town/Organization) (Phone #)
*Please make a copy of this for your records, and return to Habitat for Humanity York County via mail or email,
Habitat for Humanity York County ~ P.O. Box 267 ~ 4 Industrial Dr. Kennebunk, ME 04043 ~ 207.985.4850
~ www.habitatyorkcounty.org ~
Homeowner Registration and Waiver of Confidentiality
Name: ______
Address: ______
City: ______Zip Code: ______
Phone Number: ______Secondary Phone Number: ______
Other (email): ______
Income/year: ______# in Household: ______
Have you received assistance from KYCW! in the past three years? Y/N
(Income information and # in Household will only be made available for the Keep York County Warm! program)
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WAIVER OF CONFIDENTIALITY
I, ______(full name), hereby give the
______(office, job title, organization) in the town of ______permission to release my contact information in order to receive weatherization assistance (as defined by the materials listed on the Homeowner Requirements and Overview Sheet) from the Keep York County Warm! program.
I understand that by signing this waiver my information will be given to Habitat for Humanity York County and the volunteer team assigned to provide assessments and installations of materials in my home. I acknowledge that signing this waiver registers me for the Keep York County Warm! program, and that every attempt will be made to include my home in the program.*
______
(Signature) (Date)
*Number of Homes to be weatherized depends on the number of volunteers and weatherization materials available.
· If homeowner has any weatherization questions or concerns, please list those on the back of this paper.
Please make a copy of this for the homeowner, your records, and return to Habitat for Humanity York County via mail or email,
Habitat for Humanity York County ~ P.O. Box 267 ~ 4 Industrial Dr. Kennebunk, ME 04043 ~ 207.985.4850
~ www.habitatyorkcounty.org ~
Homeowner Requirements and Overview
(This page is for the homeowner to keep.)
Homeowner Requirements
Step 1: Be available for one home assessment day and one installation day
Step 2: Obtain Referral
Step 3: Sign a Homeowner Agreement Form (to be signed on assessment day)
Scope of Work to be Performed:
1. Step One Weatherization
On installation day, homes will receive the following:
Custom-Fit Window Inserts / Door Sweeps
V-Strip / Outlet Receptacle Covers
Foam Weather-strip / Insulation Foam
Pipe Insulation / Caulk
2. Step Two Weatherization
Habitat for Humanity will receive funding to support a full weatherization of five homes for Fall 2015. After a preliminary assessment of all homes, five will be chosen for this program. Homes will be selected at the discretion of trained Habitat for Humanity volunteers. Selected homeowners who choose to participate will be asked to contribute $100 toward the program for this weatherization. This weatherization will include repairs such as:
Attic / Air seal and insulate box sills and band joist
Seal wiring penetrations and stack vent penetration / Insulate BBHW supply and return pipes
Air Seal and insulate attic hatch
Seal Chimney by-pass / Main House
Install r19 unfaced FBG over existing / Windows and Doors
Other Notes:
Capable homeowners may be asked to support volunteers with installation by volunteering as well!
Homeowner MUST be home during assessment and installation.
Homeowners participating in the Step Two weatherization are asked to contribute $100 for the services.
Habitat for Humanity York County ~ P.O. Box 267 ~ 4 Industrial Dr. Kennebunk, ME 04043 ~ 207.985.4850
~ www.habitatyorkcounty.org ~