Community Services Directory
Intake and Data Correction Form
Updated: June 2008
Agency Name (maximum 50 characters):
Street Address: (maximum 35 characters):
City: State (2-letter code): ZIP code:
Mailing Address (if different) (35 characters):
Telephone - Office Answering machine or service 24-hours TDD
FAX - E-mail:
Web Site:
Funding Sources: Dues/memberships Fees (fee for service) Grants/private United Way City County State Federal
Purpose or Mission of Agency:
Days & Hours (50 characters):
Person In Charge (30 characters) :Title (25 characters):
Program Name (maximum 50 characters):
City: State: ZIP code:
Person In Charge (30 characters) : Title (25 characters):
Description of Services
Uses Volunteers to provide services? Services Aids (check all that apply): Architecturally accessible Near bus lines Parking available Add other service aids (write in)
Fees:
Languages Spoken (besides English):
Eligibility (60 characters):
Area Served (geographical such as ZIP code, city, county, area, etc.) (60 characters):
Application/Intake Procedure (check all that apply): E-mail Telephone Walk-in Web site Write Referral from: Other:
ALL BELOW IS REQUIRED INFORMATION
I agree that all information is accurate and complete, and I understand that all information provided here is acceptable to publish.
Yes No
Name and title:
E-mail:
Direct Phone (not agency):
Date:
You should see a confirmation page after you complete all required information and click on the "Submit Form" button. If you don't see the confirmation page, please e-mail the webmaster
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