Single Moms Car Repair Team Request for Assistance

Your Name

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you live in the Charlotte Metro area? (we only service cars in the Charlotte, NC metro area) *

Yes

No

Are you a single mom *

Yes

No

Do you have children living at home with you? *

Yes

No

Are you a senior citizen (65+) *

Yes

No

Do you have an adult male living in your home? *

Yes

No

Are you a returning or new client? *

Returning Client

New Client

Is the vehicle registered in your name? *

(you will be required to submit a picture of your title/registration)

Yes

No

Please check if this is *

Routine maintenance

Repair

I understand the Auto Repair Ministry is limited to repairs that can be completed in a few hours, and the ministry will have to review the repairs needed to determine if they are within the ministry’s scope. *

I Understand

I understand the Auto Repair Ministry can refuse to make any repairs if they determine the vehicle is unsafe to drive. I understand this decision is not made lightly and is made with the client’s best interests in mind. *

I understand

I understand the Auto Repair Ministry receives more requests for help than they can make. *

I Understand

It is my responsibility to confirm by Wednesday evening the week of the repair that I will be participating. The Auto Repair Ministry will also send a reminder. However, in the event my contact phone number is not working, I will call or text from another phone so our administrative coordinator can confirm. *

I understand

After two no-shows, the Auto Repair Ministry can choose to no longer schedule me for services. A no-show is defined as: (1) not confirming the week of my repair; (2) confirming the week of my repair and not arriving at my scheduled time; (3) cancelling late Friday evening/Saturday morning. *

I Understand

It is my responsibility to stay with the vehicle while repairs are made. I cannot drop off my vehicle or leave the church campus. *

I Understand

I understand the mechanic team will provide me with a parts estimate prior to buying parts, and I will reimburse the ministry with cash, check or credit/debit card. *

I understand

I have reviewed the data provided and attest that it is accurate and true.

I understand

I understand, in consideration of receipt of voluntary services from the participants of the Give Love Project Auto Repair Ministry sponsored by Next Level Church, I hereby release and agree to hold harmless and indemnity Next Level Church, it's employees, classes, organizations, members, attendees, trustees, officers and agents from and against any and all liability, claims, demands, actions, damages, expenses and costs, including attorney's fees and loss of judgments of whatsoever kind and nature which may result from or arise out of services provided for me or for such services which may benefit me whether or not resulting, in whole or in part from the negligence or from acts of omissions of either the participants in the Give Love Project Auto Repair Ministry of Next Level Church, it's employees, classes, organizations, members, attendees, trustees, officers and agents. *

I understand