NEW CLIENT APPLICATION

Completing this form does not guarantee an appointment. Due to the high volume of individuals needing assistance, wait time could take up to a month or more.

First name

Last name

Date of Birth

Address

Phone

1. How did you hear about Agape Center Lynchburg?

2. How many people live in your household?

3. What is your current housing arrangement?

4. Are you currently employed? If so, is it full-time or part-time?

5. What is your approximate monthly income?

6. Do you currently participate in any government assistance programs? If so, which ones?

7. What is your current high-priority need?

8. Do you have RELIABLE transportation both to and from the Agape Center once a month?

9. Please read our NO-SHOW / CANCELLATION POLICY and initial below if you agree to abide by it. (found in the "NEED HELP" section above)

10. Please read the STATE / FEDERAL REPORTING POLICY guidelines and initial below stating that you understand our responsibility with this policy. (found in the "NEED HELP" section above)

Thanks for submitting!