Benevolent Intake Form

In making a request for support, you MUST INCLUDE a bank statement or screenshots with a minimum of 30 days of transactions. If you are requesting help with bills / utilities, PLEASE INCLUDE a copy or screenshot of the bill. Your Intake Form will not be accepted without this information.

Date:

Name:

Address:

Phone:

Email:

This address will receive a confirmation email

Social Insurance Number:

Do you attend a church? If so please share the name:

Who referred you to LCA? Please share the name or organization:

Have you requested help from LCA before?

Yes No

Marital status:

Age:

Number of people in your household:

Others in your household (Name & Age):

Please list all sources of income for your household INCLUDING dollar amounts:

A copy of current 30 day bank statement is required. This can be emailed to info@lakecountrychurch.com, or attached to this form:

Bank Statement (pdf or jpg)

Upload (8MB)

Amount of Child Tax Credit (if applicable):

Total Income amount (monthly for HOUSEHOLD)):

Rent or mortgage amount:

Utilities & amount for each:

Briefly explain the situation that has placed you in need:

Drugs or any other medications?

Essential for LCA to know? (advocate, dependants, disabilities etc.)

By submitting this intake form I acknowledge this information is true and accurate. I authorize Lake Country Alliance church to use this information to process my request. Due to the Personal Information Protection Act (PIPA), we require your permission to keep your personal response form information on file.

I understand and acknowledge that the personal information that I have provided on this form may be used by LCA staff and volunteer resource teams to provide service.

I understand

I hereby authorize LCA to obtain and/or release information they deem necessary regarding myself from or to any person, firm, corporation or society required in order to assist and support me. I hereby release LCA and its staff and volunteers from all manner of liability, claim or demand I may or will have as a result of their obtaining and/or releasing information.

I agree

Please state briefly your specific need.

Lake Coutry Alliance Church
12025 Oceola Road
Lake Country, BC V4V 1H1
(250) 766-4433 | info@lakecountrychurch.com

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Benevolent Intake Form

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