Golf Classic Volunteers

Referral for Operation Weatherization

Thank you for referring your client to the Operation Weatherization Program. By completing this online form, we will soon thereafter contact your client for additional information.  Please have all referrals turned into the Operation Weatherization coordinators no later than October 3rd, 2011.  

You can reach the program coordinators at 765-608-3067.

Agency Name : 
Case Manager Name : 
Case Manager Phone : 
Case Manager Email : 

I am referring:

Client First and Last Name : 
Client Address : 
City, State and Zip : 
Client Phone : 
Email (Optional) : 
 
Do you own, rent, or rent to own this home?
 Own
 Rent
 Rent to Own
No. of household members (Including self): : 
 Adults (19-up)
 Teens (13-18)
 Children (0-12)
Is anyone in the house legally disabled?
 Yes
 No
If yes, who?
 Self
 Other Adult in Home
 Senior (60 or over)
 Child or Teen
This dwelling is a: : 
 1 Story
 2 Story
 Mobile Home
 Apartment
The primary heat source is: : 
 Natural Gas
 Total Electric
 Propane
 None of the Above
Utilities included in rent: : 
 Natural Gas
 Electric
 Both
Do you own a ladder?
 Yes
 No
 Step Ladder
 Extension Ladder
How many bedrooms?
 One
 Two
 Three
 Four or More
Which three rooms in your home are the coldest (most concerned about keeping warm)?
In these rooms, how many windows and outside are there?
Are you or another adult in the home available on Saturday, November 5th?
 Yes
 No
Approximately how many minutes does it take to reach town from your home?