MVPSF Senior Care Program
The Mountain View Public Safety Foundation (MVPSF) is sponsoring a Senior Care Program to support older adults in our community who need help with home repairs. Through volunteer efforts and grant funding, MVPSF will provide assistance to seniors who are physically unable to complete certain household tasks or cannot afford to hire professional help. This program is available exclusively to residents of Mountain View and its immediate surrounding areas.
Program Eligibility and Review Process
Applications will be reviewed to assess eligibility for program participation. A site visit may be conducted by staff or volunteers as part of the evaluation process. Approved projects will be scheduled based on the availability of volunteer support and funding. Repairs and services must directly support the well-being or safety of the resident to be eligible. One-time cleanups related to excess clutter or other health and safety hazards may be considered; however, ongoing housekeeping or general cleaning services are not included under this program.
TODAY'S DATE:
APPLICATION:
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RESIDENT CONTACT INFORMATION:
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PERSON COMPLETING THIS FORM (i.e. Social/Case worker, Services Coordinator, Caretaker, Guardian, Son/Daughter, Relative, Family Friend) :
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Household members information:
Name of Household Member
Relationship to Applicant
Age
1.)
2.)
3.)
4.)
5.)
6.)
Residence Information:
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Type of Residence
How long have you lived here?
Approx. Size (Sq. Ft)
Single Family
Condo/Townhome
Apartment
Mobile Home/RV
General Household
Painting touch-up
Remove Trip Hazards
Video & Audio hookups
Install smoke detector(s)
Install Co2 Detector(s)
Other
Dining/Living Room area
Clean/remove carpets & rugs
Move furniture for easier access
Other
Kitchen/Bathroom
Remove Trip Hazards
Replace faucet
Replace shower head
Install grab bars & other items for disabled residents
Repair Toilet
Replace/Install towel rack
Other
Bedroom(s)
Flip mattress
Move furniture for easier access
Clean/remove carpet & rugs
Other
Outdoor Areas
Sweep & clean porch/patio
Wipe down exterior windows
Fence repair
Remove fire hazards
Other
Other work needed? : (Please be specific)
What repair(s) need priority? : (Please explain below)
What challenges have kept you from completing the requested repairs? Please explain:
How did you hear about MVPSF Senior Care Program?
Authorization and Verification (Please check the boxes below)
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Optional: If possible, please provide a picture of the repair.
An additional photo of the area will help us better understand the need.
I, the undersigned, affirm that the information provided in this application is accurate and complete, and I accept the terms and conditions as stated, with the understanding that false information may result in disqualification.
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Signature of Applicant
Submit
Submit
Should be Empty: