Application for Assistance

Cleaning for a Cause

Assistance Request Form
Thank you for your interest in receiving free cleaning with Routine Clean and the Cleaning for a Cause program.

Eligibility:
- Any family that is burned out caring for a loved one with special needs that could use some help cleaning around the house.
- Anyone with a severe illness, disease, or injury that has drastically affected their life.
- If you have suffered mental or physical abuse and need some help cleaning up.
You may fill out the form below for yourself, or on behalf of someone you know who has agreed to receive our services.

We clean for as many people as we can, but we do this 1-2 times per week at the moment. We'll get approved cleanings scheduled ASAP and we're looking forward to serving you and hopefully making your day a little brighter. We may take pictures during the cleaning to promote our program, but they will not contain names or any sensitive information.
Who Needs Assistance?*

MyselfSomeone else
Your Name*

First NameLast Name
Your Email *
example@example.com
Phone Number

Area CodePhone Number
If requesting on behalf of someone else, please list as much information as possible about the recipient that you are applying on behalf of below. *
Address of Recipient*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Can We Help?*

Whole House CleaningPartial House CleaningOther
Please provide some details on the need for assistance for yourself of the person/family in need of some love and kindness sent their way. *
May we pray for you or someone you know today?*
Should be Empty:

Cleaning for a Cause