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Simple. Private. Safe.

Welcome to our Client Intake Page!

Below you can start the process by filling in the information.

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REMEMBER - YOU WILL NEED THE FOLLOWING FOR YOUR FIRST VISIT:

1. Photo ID

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2. You must live in Beaufort County

If your ID does not have a Beaufort County address, you must have a piece of mail with your name and Beaufort County address.

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3. Food Stamp & Medicaid recipients qualify

Bring your card with you.

CLIENT INFO

Birthday

EMERGENCY CONTACT INFO

INTAKE INFORMATION

Gender:
MALE
FEMALE
Are you Hispanic or Latino/a?
YES
NO
Ethnicity:
Marital Status:
Single
Married
Divorced
Widowed
Employed?
YES
NO
Government Benefits Received:
Food Stamp Status:
Receiving
Denied
Applied & Waiting
Have Not Applied Yet
Need to Rectify

INCOME INFORMATION

ENTER THE AMOUNT BELOW OF YOUR HOUSEHOLD INCOME:

LIST WHO LIVES IN HOME

Select All That Apply
Select All That Apply
Select All That Apply
Select All That Apply

CONSENT FOR RELEASE OF INFORMATION AND SHARING & LIABILITY RELEASE FORM

In order to better serve my family's needs and to determine the best use of resources, I hereby authorize Eagle's Wings to release or share the information from this application. This sharing of information will be used only for my family's best interests and guidance for future assistance from Eagle's Wings or other organizations. I understand the need for my information to be released or shared. I understand that some information will be placed in a central file for coordinating assistance among community organizations. This information is required to be kept in strict confidence by each organization. I also understand that all food given to me is protected by the Bill Emerson Good Samaritan Act. This Act states - "A nonprofit organization shall not be subject to civil or criminal liability arising from the nature, age, packaging, or condition of apparently fit grocery product that the nonprofit organization received as a donation in good faith from a person or gleaner for ultimate distribution to 'needy'." If you wish to obtain a copy of this Law, please make this request at the front desk.

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