2024 Neighbor Application-CONFIDENTIAL

OMP can complete projects in a 30 mile radius/30 minute drive of our host locations. Do you live close to or in:*

Northwest Arkansas (Bentonville, Fayetteville)Little Rock/or near North Little RockWithin North Little Rock city limits (NLR Addresses only)Central Arkansas (Conway, Maumelle)Close to Clinton, ARClose to Forrest City, ArClose to West Memphis, Ar

Applicant Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address, if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Homeowner Name, if different from applicant

First NameLast Name

Homeowner Phone Number, if different from applicant

Please enter a valid phone number.

Have you received assistance from OMP in the last 3 years?*

YesNo

Is anyone in your home having difficulty entering or exiting your home? Explain.

Work requested (OMP does not do major construction or remodeling, roofing, saggy floors, new fence construction, plumbing, electrical, utility work, appliance repair, heating and cooling, major fencerow clearing or tree/stump removal)*

If other work is requested, please describe:

If OMP is unable to get to your request, may we share your information and needs with other agencies that might be able to offer assistance?*

YesNo

Can you help furnish materials?

Example: Do you already have paint or lumber that could be used or do you have a way to supplement the cost of your project?

Do you have any pets? If yes, please specify how many and what kind below. *

Are you a veteran or veteran's spouse?*

YesNo

Is this request for someone 55 or older?*

YesNo

Is this request for someone 17 or younger?*

YesNo

What family situation would be helpful for us to know? (illness, disability, etc.)

Tell us about yourself. What are some things you enjoy doing or ways you enjoy serving your family, friends, or neighbors?

How did you hear about OMP? Please list name of agency, contact at agency, agency email, agency phone number

By requesting work from Ozark Mission Project (OMP) I understand and agree that unskilled youth and adults will be providing free labor, if my residence is selected. In doing so, I acknowledge that OMP does not guarantee its work, or provide any warranties, express or implied, including but not limited to warranties relating to the quality of workmanship or materials, merchantability, fitness for a particular use, habitability, or the completeness of the work that will be performed.

I HEREBY AGREE TO WAIVE, RELEASE, DISCHARGE AND HOLD HARMLESS OMP AND ANY RELATED AGENCY, CONFERENCE, DISTRICT, LOCAL CHURCH, CHURCH MEMBER OR ATTENDEE, EMPLOYEE, VOLUNTEER, OR AGENT OF OMP, FROM ANY AND ALL LIABILITY, ACTIONS, CAUSES OF ACTIONS, CLAIMS OR DEMANDS FOR PERSONAL ILLNESS OR INJURY, DEATH OR PROPERTY DAMAGE OF ANY KIND OR NATURE, OR THAT OTHERWISE RELATE TO MY PARTICIPATION OR INVOLVEMENT WITH OMP OR THE OMP SPONSORED WORK PERFORMED AT MY RESIDENCE.

I agree: (i) To be present while OMP is working at my residence, (ii) To receive no compensation from the use and/or the sale of any upgrade or project that OMP has installed at my residence, (iii) That neither I nor any resident or visitor to my residence will participate in the following activities while OMP is present: drug or alcohol use, weapon use, foul or abusive language directed at OMP staff or volunteers, or any activity that could cause harm to OMP staff or volunteers, (iv) That if any of the aforementioned behaviors occur, OMP reserves the right to stop work at my residence, even if the work is unfinished, and (v) To the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to print and other public media as may be deemed appropriate by OMP. (I understand that I may be identifiable from such photographic or electronic reproduction.)

By signing below, I attest that the information provided above is true and accurate, to the best of my knowledge and the homeowner (if other than applicant) is aware of this application, and agree to the terms and agreements stated above.*

**If information was filled out by someone other than the applicant, please list by whom: