Rake Up Green Bay Service Request Form

Rake Up Green Bay Service Request Form

To be considered for assistance, you must complete and submit this form. Please note, however: submitting this form doesn’t guarantee service.
Information about the person needing service:
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City

Zip Code
Phone Number *
Who should we contact with questions? *

The person named above Someone else
If someone else, their name:

First Name Last Name
Phone Number
Email
Relationship to person needing service:
What is your reason for requesting this service? Due to limited resources, we would like to focus our efforts on the homeowners in our area who are most in need. *

No one else in the area to assist Physical disability Financial limitations Other
If you selected 'Other' above, please briefly explain:
Approximately how many leaf-dropping trees does your yard have (front and back combined)? *
Do you have a pet? Please note: Homeowners are responsible for clean-up of pet waste in their yards prior to volunteers' arrival. *

No Dog Cat Other
Can you provide any rakes and, if so, how many? *
Can you provide any tarps and, if so, how many? *
How did you hear about this opportunity? *

ADRC of Brown County Brown County United Way Volunteer Center of Brown County Other
I give permission for my photo to be used by the participating organizations for promotional purposes. *

Yes No
Please read before submitting:

I understand that volunteers do the work. I release from any and all liability the volunteers, the Volunteer Center of Brown County, and any partnering or sponsoring agencies through my consent to participate in this program. I understand that this request may not be completed due to resource limitations and at the discretion of the Volunteer Center. I give permission to release my contact information to the volunteer(s) assigned to me so they may contact me to arrange a day and time for the services(s) to be completed. I acknowledge my understanding of the above-mentioned information and my willingness to participate in this program.
Signature

Clear
Should be Empty:

Rake Up Green Bay Service Request Form

Information about the person needing service: