Assistance Request Form Assistance Request Form Name * First Name Last Name Are you a resident of Kootenai County? * * Yes No What is your phone number? * (###) ### #### Email * What is your birthdate? * MM DD YYYY Have you ever contacted Love INC before? * * No Yes Who referred you to Love INC? * * Assistance Request * * 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. Thank you! We will call you in the next 24-48hrs.
