Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Disability

Disabled as recognized by the government

Disabled but currently not recognized by the government

Choose all that apply

What ethnicity(s) best describes you

White

African American

African

American Indian

Asian

Hispanic

Other

Service Area Agreement *

I understand Love INC of Worthington services are for residents of Nobles County and within that, certain services are only available within the town of Worthington. I agree to receive benefits, if I qualify and there are resources available, under this understanding.

I understand and agree

I don't agree and wish to end the process

Scope of Services Agreement *

This form is the starting point of the process that Love INC uses to open a new file. Love INC may differ from others you have contacted for help. Love INC is a ministry of 19 local churches in the community and we work to connect people with the best resources available to them in the Worthington area. We are NOT AN URGENT service agency and we DO NOT PROVIDE MONEY nor PAY BILLS. Instead, we assist you in the process of finding and accessing other resources. Over the next few days, once this form is received, Love INC will contact you to get to know you better. We want to problem solve with you about your current situation. Do you understand and want to continue this process?

Yes, I understand and would like to continue the process

No, I wish to end the process

Today's Date

MM

DD

YYYY