Adopt-a-Senior Request Form - Request to be Adopted by a Volunteer!

2. Adopt-a-Senior Request Form
   
   Are you a senior living in Richmond or North Richmond? Do you need help keeping litter, weeds, and overgrowth out of your front yard and sidewalk? Sign up to be adopted by and receive free maintenance services from community volunteers.
   
   Adopt-a-Senior services are limited to the front yard, back yard, and sidewalk and may include: cleaning up debris and litter; removing weeds and tall grass; trimming and pruning plants; painting; and more. The Adopt-a-Senior Program does not provide any home repairs or other services that take place inside of the home. Volunteers are not professionals and do not receive training by the Adopt-a-Senior program in landscaping, gardening, painting, etc.
   
   
4. Eligibility Requirements
   • Own or rent a single-family home in City of Richmond or North Richmond - home ownership will be verified by City staff
   • Be at least 55 years old
6. Documents Required
   • Completed application
   • Valid identification
   • (Renters only) Signed letter of permission from the property owner
8. Personal Information
10. First Name*
11. Last Name*
12. Date of Birth *
14. Gender
    -- Select One --MaleFemalePrefer not to say
15. Address*
17. City*
18. State*
19. Zip Code*
21. Email Address*
22. Preferred Phone Number*
24. Valid Identification
    Acceptable forms of identification include:
    - An unexpired identification card or driver's license, or
    - An unexpired passport or passport card
26. Please upload an acceptable form of identification below.*
28. Homeowner Information
30. Do you own or rent your home?*

    1. I rent my home
    2. I own my home
32. (For Renters) Letter of Permission from Property Owner
    If you currently rent your home and are requesting services, you must provide a signed letter of permission from the property owner. Download the letter of permission template here. Please upload the signed letter of permission below.*
34. Services Requested
    NOTE: The Adopt-a-Senior program aims to provide only basic maintenance services. Volunteers might not have professional training in landscaping, gardening, painting, etc. Adopt-a-Senior will provide trash bags and gloves to volunteers upon request, and volunteers are expected to bring their own tools.
36. For which part(s) of the property are you requesting services? (Check all that apply)*

    1. Front yard
    2. Back yard
    3. Sidewalk
37. What services do you wish to receive? (Check all that apply)*

    1. Pick up debris/litter
    2. Remove weeds and tall grass
    3. Trim and prune plants and trees, and/or water plants
    4. Paint fence (NOTE: Painting supplies must be provided by the applicant.)
    5. Other
39. Please describe other services you wish to receive. Other services may not be eligible.*
41. How often would you like to receive services?*
    -- Select One --One time onlyOnce every 2 weeksOnce a monthOnce every 2 monthsNo preference / As available
42. What time of the day/week would you prefer to receive services? (Check all that apply)*

    1. Morning
    2. Afternoon
    3. Evenings

    1. Weekends
    2. Weekdays
44. How would you like to be matched with a volunteer? (Check all that apply)*

    1. A volunteer who lives or works in my neighborhood
    2. A volunteer who lives or works in Richmond
    3. Any volunteer
46. Language(s)
48. Preferred Language(s) (check all that apply)*

    1. English
    2. Spanish
    3. Other
49. Other Preferred Language(s)
51. Terms and Conditions

    Please carefully read the following statements.

    
    

    I authorize the CITY OF RICHMOND, California ("City") Adopt-a-Senior Program ("Program") and its volunteers to complete free basic beautification and maintenance services on my home/property ("Home") as specified in this application.

    
    

    I understand that if I rent my Home and am requesting Program services, I must also submit signed a Letter of Permission from the property owner and proof of home ownership from the property with this application. I further understand that without a signed Letter of Permission from the property owner, the Program and its volunteers will not be able to complete services on my Home. If I am the property owner submitting this application, completion of this application constitutes my Letter of Permission.

    
    

    I acknowledge that there is no salary or other compensation of any kind provided by the City to the Program volunteer(s) completing free services on my Home.

    
    

    I understand that Program volunteer(s) completing free services on my Home may not have certified training in landscaping, gardening, painting, and/or other skills for specialized tasks.

    
    

    I agree to allow Program volunteers to utilize my waste disposal receptacles to complete services on my property.

    
    

    I understand that the City and Program volunteer(s) may photograph or videotape my Home, me, and/or members of my household, and I give my permission for the City and Program volunteer(s) to use photographs or videotapes of my Home and me for the purpose of promoting the City and its services/programs. No compensation of any kind will be paid to me at this time or in the future for the use of my (or members of my household's) likeness.

    
    

    I hereby release the City of Richmond, its officers, agents, volunteers, and employees from any and all liability, claims, cause of action, or actions, arising out of or occasioned by bodily injuries or property damages sustained by me as a result of my participation in the Adopt-a-Senior Program.

    
    

    I also acknowledge and agree that my receipt of services from the Program may be terminated for any reason, or for no reason, and at any time by the City without notice or hearing.

    
    

    I, the undersigned, certify that the information stated on this application is true, complete and correct to the best of my knowledge and belief and is made in good faith. Any false statements made by me may be used as a basis of rejection for this application.

    
    

53. My Home Address*
55. By typing my full name below, I am electronically signing my application. I understand all information will be kept confidential and only the information required to provide the services will be disclosed to those who perform the service.*
57. How did you find out about us? *

    1. City of Richmond Webpage
    2. A Friend
    3. Flyer

    1. Facebook
    2. Twitter
    3. Other
58. If you checked other, please specify.
60. After submitting this form, you will be contacted by one of our staff to confirm receipt of your documents and to request any additional information.
62. Application approved?

    1. Yes
    2. No
63. Approved by:
64. Approval Date
    Approval Date
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65. Submit Submit and Print

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