Homeowner Candidate Special Needs Form

Homeowner Candidate (HOC) Special Needs Form
Dear Homeowner Candidate,

This form is REQUIRED.

Special Needs Form / Information Release. Please ensure to complete this section and sign the form. If you have any concerns please let Sandra Holmes (sholmes@habitattbg.org) know immediately.
Name*

First NameLast Name
Name of Spouse or Co-Applicant, if applicable. If none, write "None". *
Current Address*
Phone Number(s)*
Email*
example@example.com
Do you or anyone who will be living in your Habitat home have special needs? *
- If YES, please complete the rest of this form.
- If NO, please go to bottom of the form to sign.
Please list your family members (the ones who will be living in your Habitat home) by name, relationship, and birth date with year.
Please describe the special needs of you and/or your family member(s), and the modifications you are asking for. To verify your need, we will ask you to supply medical records. You do NOT have to attach medical records to this form.
Special Needs Release Form

I/we understand that the information in this form and medical documentation will be shared with the Physical or Occupational Therapist. I/We authorize Habitat for Humanity Tampa Bay Gulfside to give our contact information to their Physical or Occupational Therapist and for their Physical or Occupational Therapist to contact me/us directly.
over the age of 18.under the age of 18.
the legal guardian/parent of the people listed above.N/A
Signature*

Clear
Please use your mouse/cursor to sign.
Signature of Spouse/Co-Applicant (if applicable). If none, write "None". *

Clear
Please use your mouse/cursor to sign.
Should be Empty:

Homeowner Candidate (HOC) Special Needs Form

Special Needs Release Form