Form Center

2. 
4. Today's Date *
   Today's Date
6. First and Last Name(s)*
8. How you prefer to be addressed
10. Date of birth
    Date of birth
11. Date of birth (if filling out for 2 people)
    Date of birth (if filling out for 2 people)
13. Street Address in University Park*
15. Preferred Phone Number*
16. Alternate Phone Number
18. Email Address (if you routinely use)
20. Status*
    -- Select One --SingleMarriedPartneredWidowedDivorced
22. Living Arrangement*
    -- Select One --With spouse/partner/family/friendAloneNon-family caregiver
24. Do you have any physical limitations or mobility problems?*

    1. Yes
    2. No
26. If yes, please provide information:
28. Are you in need of services now?*

    1. Yes
    2. No
30. Comments:
32. Please tell us something about yourself. Occupation? Volunteer work? Hobbies? Skills? Interests? Anything else you think we should know about you? *
34. Would you be available for light volunteer tasks, e.g. making phone calls, stuffing envelopes?*

    1. Yes
    2. No
36. Indicate any allergies we should know about, e.g. highly allergic to cats or dogs: *
38. If you have pet(s) please tell us about them:
40. Please have my name/contact info listed in an HHUP Member Directory, to be shared with other HHUP Members only.*

    1. I agree
    2. I do not agree
42. Emergency Contact
44. Name*
45. Relationship*
47. City*
48. State*
50. Phone Number*
51. Cell Phone Number
53. HHUP Membership Agreement
    Helping Hands University Park (HHUP): HHUP helps neighbors remain in their homes as they age (“age in place”). We do this through volunteer activities, educational and social programs, and through partnerships with other individuals and organizations that complement our volunteer activities. By engaging all residents in these activities, UP enhances the quality of life of the entire community.
55. Services
    HHUP will provide services to its members through volunteers. All HHUP volunteers who are sent to members’ homes have been vetted. The most common direct-to-members services that HHUP volunteers provide are transportation, light handyman work, help with electronic devices, friendly phone calls and visits, and convenience services such as running errands, preparing occasional meals and other routine activities. HHUP will not provide medical or home health services or major home repairs and inspections.
57. Fees
    As a Town Committee, we do not require membership fees. However, as a non-profit organization, we welcome members’ charitable donations, payable to: The Town of University Park, indicating HHUP as the beneficiary.
59. Termination of Agreement
    Membership may be terminated in two ways: (1) By the member: Members may terminate this Agreement at any time by giving written notice to HHUP; or (2) by HHUP: HHUP reserves the right to terminate this Agreement with a member whenever the HHUP Committee determines that it is in the best interest of HHUP.
61. Privacy
    HHUP will take all reasonable steps to protect the personal information of its members. However, where concerns regarding a member’s health or safety arise, HHUP reserves the right to contact those listed below under member’s emergency contact information or any others HHUP deems appropriate. In addition, only at the request of a member, HHUP may disclose contact information to connect a member with a third-party vendor.
63. Waiver of Liability
    HHUP Members agree to indemnify HHUP and its staff and volunteers and agree to hold it and them harmless for any loss, damage, expense, or liability of any kind arising out of the acts or omissions of its staff or volunteers, including but not limited to any action or claim a member or a member’s heirs, assigns, or insurance company might bring for negligence, personal injury or invasion of privacy. Members further understand that HHUP is not affiliated with or otherwise responsible for the acts or omissions of any third party vendors. Members shall release and hold HHUP and its staff and volunteers harmless from any and all responsibility or liability arising from the acts or omissions of its staff or volunteers.
65. Health Care
    HHUP does not provide emergency or other health care services, is not a health care administrator, and does not employ licensed health professionals or social workers. Each of the undersigned applicants for HHUP membership states that he/she has read and understands the above terms of membership and agrees that he/she and their respective heirs, successors, agents, and legal representatives will be bound by those terms. When a membership is renewed, it will remain subject to this agreement.
67. Each of the undersigned applicants for HHUP membership states that he/she has read and understands the above terms of membership and agrees that he/she and their respective heirs, successors, agents, and legal representatives will be bound by those terms.
69. eSignature*
    By typing your name, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.
70. eSignature (if household of 2 or more)
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field