What is Love INC
Who We Are
How We Can Help
Church Partners
Get Involved
Contact
Give
Jobs For Life
Assistance Request Form
*
Indicates required field
Name
*
First
Last
Are you a resident of Kootenai County?
*
Yes
No
Phone Number
*
Email
*
Birthdate
*
MM/DD/YYYY
Have you ever contacted Love INC before?
*
Yes
No
Who referred you to Love INC?
*
Church, Agency, Family member, friend.
Assistance Request
*
Please indicate what you are seeking assistance for. There are no guarantees Love INC will be able to assist with your request, but we will listen, problem-solve with you, and do our best to come up with an appropriate solution.
AUTHORIZATION FOR RELEASE OF INFORMATION TO AGENCIES, CHURCHES AND ORGANIZATIONS AFFILIATED WITH LOVE INC OF KOOTENAI COUNTY *
I hereby authorize Love INC of Kootenai County to disclose my personal information contained in or relating to my request for assistance submitted to Love INC and its affiliated agencies, churches, and organizations. I understand and acknowledge that Love INC has no administrative oversight or control over such affiliated agencies and organizations. I further acknowledge and understand that Love INC has no administrative oversight or control over the use and dissemination of such information by its affiliated agencies and organizations. I hereby release and hold harmless Love INC and its affiliated agencies, churches, and organizations from any and all liability relating to or arising out of the use and dissemination of such personal information by Love INC and its affiliated agencies and organizations. I hereby revoke any previously dated Consent to Release of Information to Love INC of Kootenai County.
*
By clicking on the checkbox, you are signing this document.
Submit
What is Love INC
Who We Are
How We Can Help
Church Partners
Get Involved
Contact
Give
Jobs For Life
Support Us