People of Impact Home Makeover Request Form

People of Impact Home Makeover Request Form

Please fill out the form below to request a home makeover. We will review your request and get back to you shortly.
Individual or Referring Agency Information
How is this nominee being referred
Outside Agency Type
Referring Person or Agency Name (type Self if self-referring)
Referring Person/ Agency Rep Title (type Self if self-referring)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Why do you think we should choose this client for a makeover?
Family Information

Clients must be referred and pre-verified by an approved partner agency before submission.
Nominee's Full Name

First NameLast Name
Nominee's Email Address
example@example.com
Nominee's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Nominee's Website (Type N/A if they don't have a website)
Project Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Family Members (choose all that apply)
Room's for Makeover (choose all that apply)
Needs (choose all that apply)
Description of other Makeover Needs
Special Requests or Preferences (Optional)
Upload a short video sharing the recipient's story or actions in the community

MP4, MOV, AVI, WMV, FLV, MKV
Cancelof
Should be Empty:

Individual or Referring Agency Information