Home Cleaning Assistance Request Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Type of Service Requested

Please specify

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Frequency

Preferred Date and Time

Date

Hour MinutesAM/PM Option

Number of Rooms to be Cleaned

Additional Services Requested:

Cleaning Supplies

If Mamas’ Provision is providing supplies, do you have any allergies to any cleaning supplies?

Type of Property

Other

Any Pets?

Number of Bedrooms

Provide any specific instructions or requests here, such as areas of focus, cleaning product preferences, or any other special requirements.

Terms and Conditions:

By submitting this request, I acknowledge and agree to the following:

The service requested will be scheduled based on availability.
Changes or cancellations to the service appointment must be made at least 24 hours in advance.
The service provider will not be liable for any damages or losses resulting from the cleaning service.
Members and volunteers will not be able to enter home until pets are put away, for safety purposes.
I understand that submitting this application does not guarantee service. Cleaning assistance is provided based on volunteer availability, safety, service area, and the needs of the organization. I agree to provide accurate information and to communicate any safety concerns or changes before the visit. I understand that volunteers may decline tasks that are unsafe, hazardous, or outside the organization's approved services.

Signature

Date

Service Details: