Lead Safe Homes Program Interest Form

Section 1. Interested Party Information

First Name

Last Name

Gender

Street

City

State

Zip Code

Preferred Method of Contact

Primary Phone

Format 999-999-9999

Primary Contact Preferred Language?

Ethnicity (optional)

Race (optional)

How did you hear about this program?

Please provide more detail on how you heard about this program

Section 2: Property & Household Information

Which of the following statements applies to you?

I rent my home and live in it full timeI own my home and live in it full time

Please provide the contact information for the Property Owner

Property Owner Name

Property Owner Phone Number

Property Owner Email Address

Type of Home

How many people live in your household?

Has your home recently been remodeled?

Do either of the following live in your home? Note: This program requires that you have either a child under 6 in the home or a pregnant person to qualify.

How many children under 6 live at your home?

When you click Submit, please allow a few moments for the form to process — you only need to click once. If any required fields are missing, you’ll be prompted to complete them before resubmitting.

Thank you for taking the time to complete our Interest Form!

Habitat for Humanity East Bay/Silicon Valley Home Preservation Department