Home & Yard Maintenance
Volunteer Service
Date of Event or Service: __________________
I am a senior citizen or disabled and need assistance with my home and yard maintenance from
Solid Rock Bible Church.
Applicant Name: ___________________________________Date of Birth: ________________
Address: _______________________________________ Home Phone: __________________
City: ________________________ Zip code: _________ Cell Phone: ____________________
Marital status of applicant(s): Single ________ Married ________ Widow/Widower ________
Do you own or rent your home? ________ is there a co-owner? __________
Number of individuals living in the household with the applicant(s): __________
Names, ages and relationship of these individuals to the applicant(s):
_____________________________________________________________________________
Name
Relationship
Age
_____________________________________________________________________________
Name
Relationship
Age
_____________________________________________________________________________
Name
Relationship
Age
Home & Yard Maintenance Volunteer Service (Liability Waiver)
Effective Date: 02/16/12
Document Location: Office Drive: Church Office/Forms
Length of time at this residence ____________________ approximate age of Home _________
Is home insured? ____________ Name of insurance company ___________________________
Please detail what yard work or home maintenance is needed. If yard work, please include
approximate size of yard.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_________________________________________________________________________________
Do you have yard tools that a volunteer could use? Yes ______ No ______. If yes, what tools do you
have?
______________________________________________________________________________
Please read below carefully
I/we understand that any information received will be kept strictly confidential. I/we hereby certify
that the foregoing information is true and complete to the best of my/our knowledge, and inquires
may be made to verify the statements made herein. I/we further certify that the property address
contained herein is my/our principal place of residency and I am the owner (or co-owner) of the
property.
Furthermore, I/we hereby waiver and release Solid Rock Bible Church located at 670 Church St.,
Plymouth, MI 48186, together its board members, volunteers, agents and representatives, from any
claim, injury, damage or cause of action of any kind arising out of my participation in this service
program. I/we understand that all work will be done by volunteers and neither Solid Rock Bible
Home & Yard Maintenance Volunteer Service (Liability Waiver)
Effective Date: 02/16/12
Document Location: Office Drive: Church Office/Forms
Church nor any of its volunteers provide any warranty, either expressed or implied on the work
done.
I/we understand photos may be taken of the volunteers while they are completing their tasks and
give permission for those photos to be used in Solid Rock Bible Church materials.
I will be home on ______________________ between the hours of __________ and
__________ when the work requested is to be completed.
____________________________________ ___________________________________
Signature of Applicant
Date
Signature of Co-Applicant
Home & Yard Maintenance Volunteer Service (Liability Waiver)
Effective Date: 02/16/12
Document Location: Office Drive: Church Office/Forms
Date