Enrollment Form

The purpose of this LeadCare Cook County Lead Service Line Replacement Program (“Program”) Enrollment Form (“Form”) is to help you determine eligibility for the Program. To apply for the Program, complete and submit this Form. Doing so will mean you consent to Elevate Energy (“Elevate”) and contractors contracted by Elevate (hereinafter “contractors”) carrying out Program activities. Program activities may include, but are not limited to confirming your eligibility, accessing the property identified in this Form (“Property”) at an agreed-upon time to determine if the water service line is made of lead or galvanized material, performing associated activities to confirm eligibility, and replacing your service line if it is determined to contain lead or galvanized material.

Eligibility Requirements

Child care providers are eligible for the Program if they meet the following requirements:

  • They run a child care facility (“Facility”) which must be owned or rented by the person applying. If the child care provider rents the Facility, the Owner of the Property out of which the Facility is operated must also agree to and complete a separate application and consent form.
  • The Facility is based in suburban Cook County.
  • The Program determines that the service line connecting the Property to the water main is made from lead or galvanized material.

Eligible child care providers can apply online by filling out and submitting this Form. If you don’t own the Property where your Facility operates, you still need to complete this Form and provide the name of the Property Owner. We will also have the Property Owner complete an application and consent form.

LeadCare Cook County Lead Service Line Replacement Program Application and Consent Form

Facility Information


If you are a license - exempt provider, please leave this field blank
Facility Address
Please provide the property address of your child care facility:




Provider Contact Information
Contact information for the provider who operates the child care facility:







Owner Contact Information
If no, please list the contact information for the Property Owner of your child care Facility. We will contact the Owner for additional approval to participate in LeadCare Cook County. Please be sure to obtain the Owner's approval to provide their contact information to us. 




Authorization
  • Replace the service line from the water main tap to its first fitting inside the Property that serves the Facility if it is determined that it is made of lead or galvanized material.
  • Make any interior plumbing modifications in the Property necessary to replace the service line to the Facility in accordance with the Program Terms below.
You have the right, and are encouraged, to consult with an attorney if you have questions about this Form and/or the Program Terms below.
Program Terms and Conditions
In addition to the authorizations above, and other information in this Form, the following are the legal terms and conditions that govern your participation in the Program. You understand that by submitting this Form you are agreeing to these Program Terms and that upon submission of this Form by you, a binding legal agreement between you and Elevate is formed:
  • You have the legal right and authority to submit this Form and to grant Elevate  and Program contractors the rights set forth in this Form.
  • You are at least 18 years old.
  • You understand that determination of eligibility for participation in the Program is in the sole discretion of Elevate. Elevate complies with all applicable laws including, but not limited to laws regarding non-discrimination and equal opportunity regardless of race, color, religion, sex, sexual orientation, gender identity or national origin.
  • You certify that if there are any tenants or other residents of the Property besides you, you will provide advance notice to them of the scheduled Program work.
  • You agree that you are responsible for ensuring that the Property is in a safe and sanitary condition and you understand that if Elevate determines that safe and sanitary conditions do not exist, a replacement will not be done.
  • Elevate may share any information you provide to us or that we obtain as a result of your application to, and/or participation in, the Program with third parties including, but not limited to, Cook County and the Illinois Department of Public Health. You can review our privacy policy which has more information about how we may use your information at https://leadcareillinois.org/privacy-policy
  • We may contact you about other programs you may be eligible to participate in. You may opt out of receiving those communications by following the instructions for opting out in those communications.
  • You may opt-out of the Program at any time before seven (7) calendar days prior to service line replacement work beginning. You must do so in writing to us which you may do by sending an email to info@leadcarecookcounty.org. 
  • There will be a temporary interruption of water service to the Property during the replacement of the service line. You will be responsible for notifying other tenants or occupants, if any, of the Property of the temporary interruption.
  • You agree that you will be at the Property on the date and at all times scheduled for any activity that requires access to the Property by Elevate and/or any contractors that performs Program work on the Property, including for service line replacement, and you will be available at all times during the service line replacement.
  • You agree that you are responsible for ensuring that the plumbing system for the Property (including, but not limited to the water meter and service line and any other components of the plumbing system, whether inside or outside of the building in which the Facility is located) will be accessible to Elevate and any contractor for all Program work. You will provide reasonable, safe, lighted, and unencumbered access to the plumbing system for the Property, including but not limited to access to the basement, wall, floor and/or other areas, as necessary, where the service line enters the Facility. You agree that you are responsible for moving, or causing to be moved, any items blocking access, such as boxes, furniture, washers, dryers, etc.
  • After installation of the new service line, you will follow flushing, filter use, and water testing instructions provided by Elevate and/or the Program contractor that perform work on the Property. Each contractor that performs Program work at the Property will warrant its work to be free from defects for a period that is no less than twelve (12) months beginning from the date of acceptance of the Program work by Elevate, however, no warranty will be provided on any type of vegetation including, but not limited to, grass, trees, shrubs, bushes or flowers. You agree that you will notify the contractor that replaced the service line immediately if you notice any new water seepage or other changes in conditions, for example, new cracking or flaking masonry, peeling paint, musky odors, etc. Elevate makes no representations or warranties of any kind including that any work performed under the Program will decrease the level of lead in water at the Facility. You agree that you will not seek to enforce any warranty or other type of claim for any work performed under the Program against Elevate. To the fullest extent allowable under applicable law, you agree to release Elevate from all liability for any claim (including any warranty claim), loss or damage of any type or kind that you or anyone visiting or occupying the Property may suffer arising out of your participation in the Program.
  • You will be responsible for watering and otherwise caring for restored landscape, including grass and other vegetation in the restored area. Neither Elevate nor any Program contractors will be responsible for care of any landscape except as explicitly stated below.
  • Elevate and/or Program contactors will use reasonable efforts to minimize and/or mitigate disturbances to exterior landscaping and hardscapes. However, exterior landscaping, hardscaping or structures on the Property that impede the replacement of the service line may be disturbed as part of the service line replacement. In such instances, restoration may be your responsibility. This includes, but is not limited to, items such as steps, patios, retaining walls, specialty or tinted concrete, structures of any type, grass, trees, shrubs, bushes and flowers. Elevate will inform you of any such responsibilities before undertaking any work that will result in such disturbances. 
In the course of Program work, unexpected conditions may be discovered that are beyond the ability of the Program to address. If that happens, we will notify you and provide proposed solutions, which may include terminating your participation in the Program and the work at the Property, or asking you to undertake necessary repairs or perform needed maintenance to bring the Property into compliance with Program requirements. It will be in your discretion to agree to do the repair or maintenance. If you do not agree, your participation in the Program will be terminated.
Elevate’s Responsibilities
If the Property is determined to be eligible for participation in the Program, Elevate (or a contractor engaged to perform work) will assume the following responsibilities in replacing your service line:
  • Provide advance notice of replacement.
  • Obtain necessary permits.
  • Engage a contractor, as needed and as determined by Elevate, to conduct investigation to confirm service line materials.
  • Engage a contractor to replace the service line.
  • Provide day-of flushing services and instructions for flushing, lead-in-water testing, and filter use post-replacement. Testing and filters will only be provided for the Facility, not the entire Property if there are multiple units in the Property.
  • Provide two free lead-in-water test kits and one (1) water pitcher with one (1) filter designed to last for six months following replacement.
  • Subject to the term above regarding unexpected conditions, we will use reasonable efforts to restore those areas of the Property that are disturbed by the Program work to the condition they were in prior to service line replacement, original wear and tear excepted. This includes restoration of the wall and/or floor if any meter and/or service line is located behind a finished wall, or under a finished floor, and restoration of the exterior to the original ground surface elevation and resodding or reseeding of grass to the condition it was in prior to replacement of the service line, original wear and tear excepted. Notwithstanding the foregoing, child care provider and/or Owner understand and agree that, while reasonable efforts will be made to restore those portions of the Property disturbed as part of the Program work to a condition as close as possible to the condition those portions of the Property were in in prior to replacement of the service line, matching the appearance, texture and/or composition of materials may not be practical and that even materials procured matching the existing materials may not match existing materials in every way, including, without limitation, appearance, texture and or composition. Neither Elevate, nor any contractor, will have any obligation to match existing materials. Any restoration by a Program contractor will be specified in writing as soon as reasonably possible. Elevate will use reasonable efforts to notify you of needed restoration work prior to such work being done, however, the need for restoration work may not be discovered until other Program work is underway or completed. Restoration work will be completed to the condition of the area prior to replacement, original wear and tear excepted. If Elevate determines the area cannot be restored to such condition, Elevate reserves the right to terminate the work unless Owner agrees to waive the restoration obligation. 
Program Definitions
Capitalized words used in this Form are defined below:
  • "Child care provider" means the person who owns and/or operates the Facility, and who submitted an application to the Program.
  • "Facility" means the child care facility located on the Property.
  • “Form” means this LeadCare Cook Country Lead Service Line Replacement Program Application and consent form.
  • “Owner” means the person or persons with legal title to the Property.
  • “Program” means the LeadCare Cook County Program.
  • “Program Terms” means the terms and conditions in this Form.
  • “Property” means the property identified in this Form, provided, however, that if there are multiple service lines servicing the Property, only the service line that services the child care facility will be replaced.
  • “Us”, "our" and/or any variation thereof or related term means the Elevate Energy in its role as Program administrator and/or any contractors contracted by Elevate that performs Program work including, but not limited to plumbing and landscape contractors. 
  • “You”, “your” and/or any variation thereof or related term means the person who has submitted this Form and the Owner.
  • In addition to the capitalized terms above, (1) the term "contractor" means any contractor that Elevate contracts with to perform Program work including, but not limited to plumbing and/or landscape work, and (2) the term "service line", unless explicitly stated otherwise, means the water service line connecting the Facility to the water main and made of lead or galvanized material that may be eligible for replacement under the Program.

Contact Information