Safe Housing & Healthy Homes Program Interest Form

The Safe Housing and Healthy Homes Program aims to increase awareness of housing-related health hazards, lead poisoning prevention, and the overall principles of a healthy home. We encourage those that are vulnerable and of low-income populations to take the necessary actions and steps to feel safe in your home and to ensure a better quality of life. If the home does test positive for lead you may be eligible for minor rehabilitation to address those lead hazards.
Please complete this survey to request more information about the program.
1.First Name(Required.)
2.Last Name(Required.)
3.Email Address(Required.)
4.Phone Number(Required.)
5.Preferred method of contact (Required.)
6.Street Address(Required.)
7.City(Required.)
8.State(Required.)
9.Zip Code(Required.)
10.Do you have a child under the age of 6 that lives in or frequently visits the home?
11.Do you or anyone in your household have asthma?
12.Do you or anyone in your household have health related issues do to
housing hazards.