PROGRAM INFORMATION UPDATE FORM
Program Name:
AKA:
Agency Name:
Physical Location Address:
,
Telephone:
Mailing Address:
Attn (contact for updates):
,
Fax:
Email:
URL:
Days & Hours:
Is your program seasonal? If yes, what are the start and end dates?
Start:
End:
Program Description:
Person in Charge of Program:
Title:
Eligibility:
Fees (including insurance programs accepted):
Intake Procedure (such as name of contact person for intake, documents or appointments required):
Languages (ability to service non-English speaking clients, languages spoken on site):
Area Served (such as town, county, region, etc):
Funding Sources:
Affiliations/Licenses/Memberships:
Do you hold all required licenses and certifications (i.e. state license for health care facility)?
Yes
No
N/A
Transportation (transportation provided? Accessible via public transportation? Parking?):
Do you accept donations- mark those you accept (1=accepted, 0=not accepted):
Clothing
Furniture
Money
Food
Toys
Other (please describe)
Can you pick up donations?
Do you use/need volunteers? If yes, adults, teens, children?
Circle the appropriate choice:
This agency is:
Nonprofit
For Profit
Religious
Government
Other (please explain)
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