Hele Box Program Application

Hele Box Program Application

A good night’s sleep is essential for life on the road! To help make that a reality, Homes On Wheels Alliance (HOWA) and Hele Outdoors are partnering to bring the Hele Box Program to low-income nomads in need of a comfortable bed. Hele Outdoors is generously donating approximately five adjustable sleeping platforms to HOWA every quarter. Specifically designed for small vehicles, these platforms feature adjustable legs to help you level out your space and maximize comfort.
Name*

First NameLast Name
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Email*
example@example.com
Enter Email Again*
example@example.com
Why do you need a Hele Box?*
What is the Year, Model, and Make of your vehicle?*
Please check the fit guide if you haven't done that yet.

Fit Guide
YesNo

Average monthly and yearly income. If 0 fill in 0. *

Rows	Monthly	Yearly
Paid work
SSI
SSDI
Social Security
Pension
Retirement disbursements
Veterans Benefits
All Income

Add a photo of your current bed or proposed bed location. *
Are you willing to send us a photo of the Hele Box in place to show Hele Outdoors how their donation is helping nomads?*
Use this space for any questions and/or comments.
Image Release
I give Homes On Wheels Alliance, Inc. permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of the Homes On Wheels Alliance, Inc. activities.
I agree that Homes On Wheels Alliance, Inc. have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the Homes On Wheels Alliance, Inc. mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions,publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet.
I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Homes On Wheels Alliance, Inc. and their agents and assigns from any and all claims which arise out of or are in any way connected with such use.
I have read and understood this consent and release.
Assumption of Risk and Release of Liability
By using the Hele Box, I acknowledge that I understand the inherent risks involved. I voluntarily assume all risks of personal injury, property damage, or death that may result from the use or misuse of this product.
I hereby release, waive, and discharge Homes on Wheels Allliance from any and all liability, claims, or causes of action arising out of or related to any loss, damage, or injury sustained by me or my property while using this product, including those caused by negligence.
I have read this document and I fully understand its terms.
Signing this document covers the Image Release, Liability Release, and your answers on the form.*

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