Home Repair Referral

Please fill out the following fields

First Name

Last Name

Phone

Address

City

Do you live within city limits?

Yes
No

State

Zip Code

Have you applied for CHIP before?

Yes
No

How many people 18 and over are there in the household?

Income for all occupants over 18 years old (Select all that apply)

Self-Employed
Employed
Social Security\SSI\SSD
Public Assistance- ADC\TANF
Unemployment
Workers Compensation
Child Support
Pensions
No Income

How did you learn about our program?

Facebook, Instagram or other Social Media
Family or Friends
GLCAP Staff Member
Newspaper
Social Service Agency (Dept. of Job & Family Services, OhioMeansJobs, etc.)
Television or Radio
Other

Additional Comments

I would like to receive an application

Please email me an application
Please send me an application by mail

I consent to receive text messages from GLCAP

Yes
No

Consent for storing submitted data

Yes, I give permission to store and process my data

Our Privacy Policy