2-1-1 Agency Application



United Way of Lake County 211 SERVICE PROVIDER APPLICATIONThank you for your interest in having your agency included in the 211 database. The application includes two basic areas:1. Agency Information: This includes general information about your organization. This does not include information about specific services you provide.2. Program Information: Programs are the services your agency offers. Please complete one program section for each program you are submitting for the 211 database.Send the completed application by email (211LakeCounty@)Please do not hesitate to call the 211 Resource Team if you have questions or need assistance with this process. We look forward to receiving your application.Thank you,United Way of Lake County 211 Resource TeamSERVICE PROVIDER APPLICATION/UPDATE FOR UNITED WAY OF LAKE COUNTY 211AGENCY INFORMATIONInclusion CriteriaDoes your organization provide services that are appropriate for inclusion in the 211 database, based on the United Way of Lake County Inclusion/Exclusion Policy (available at )? FORMCHECKBOX Yes FORMCHECKBOX NoHave you been in operation for at least six months? FORMCHECKBOX Yes FORMCHECKBOX NoGeneral Agency InformationAgency Name: FORMTEXT ????? Is your agency also commonly known by another name or abbreviation: FORMTEXT ?????Parent Agency (If legally part of another organization: FORMTEXT ?????Agency Description (describe your agency in one or two sentences): e.g. Nonprofit organization focused on supporting individuals with disabilities. FORMTEXT ?????Agency Type: FORMCHECKBOX Not-for-profit (incorporated) - tax designation FORMCHECKBOX 501(c)(3) FORMCHECKBOX 501(a) FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Not-for-profit (not incorporated) FORMCHECKBOX Government: If Yes, which level? FORMCHECKBOX Federal FORMCHECKBOX State FORMCHECKBOX County FORMCHECKBOX City FORMCHECKBOX For Profit/CommercialAgency Contact InformationAgency Website/URL: FORMTEXT ?????Agency Email: FORMTEXT ?????(for general questions from the public) Physical AddressAgency Physical Address: FORMTEXT ?????City, State: FORMTEXT ????? Zip: FORMTEXT ?????Is this office: A confidential location? FORMCHECKBOX Yes / FORMCHECKBOX No Wheelchair accessible? FORMCHECKBOX Yes / FORMCHECKBOX NoMailing Address FORMCHECKBOX Same as above (if mailing address is different, add address below)Agency Mailing Address: FORMTEXT ?????City, State: FORMTEXT ????? Zip: FORMTEXT ?????Administration Office Hours: Mon FORMTEXT ????? Tues FORMTEXT ????? Wed FORMTEXT ????? Thurs FORMTEXT ????? Fri FORMTEXT ????? Sat FORMTEXT ????? Sun FORMTEXT ?????What holidays does your agency close for? FORMTEXT ?????Agency General Information Phone #: FORMTEXT ????? Fax #: FORMTEXT ????? TDD/TTY #: FORMTEXT ????? Agency Senior Executive Name: FORMTEXT ????? Title: FORMTEXT ????? Phone: FORMTEXT ????? Email: FORMTEXT ?????Agency Primary Contact for 211 This person will receive the 211 annual update request to confirm and/or update your agency’s information in the 211 database and will be contacted if there are questions about your agency’s information in the 211 database. To ensure the accuracy of referrals, agencies that do not respond to the annual update will be subject to removal.Name: FORMTEXT ????? Title: FORMTEXT ?????Phone: FORMTEXT ????? Email: FORMTEXT ?????PROGRAM INFORMATION(Please submit one Program Information section per program)Agency Name: FORMTEXT ?????Program Name: FORMTEXT ?????Is this program commonly known by another name or abbreviation? FORMTEXT ?????Program Website/URL: FORMTEXT ?????Program Manager Name: FORMTEXT ?????Program Email Contact: FORMTEXT ?????Program Description/Primary Services Maximum of 100 words.e.g. Offers parenting skill classes to parents struggling with managing misbehavior of their children at home or school. FORMTEXT ?????Intake Procedure: FORMCHECKBOX Walk-In FORMCHECKBOX Call for appointment FORMCHECKBOX Referral required from FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Documentation Required at Intake (i.e. ID, SS card, Proof of Income etc.) Please specify: FORMTEXT ?????Program eligibility requirements: FORMCHECKBOX No restrictions or eligibility criteria. FORMCHECKBOX Other: FORMTEXT ?????e.g. Must be parents with children under 18 years old. Residency requirement: FORMCHECKBOX No residency requirement FORMCHECKBOX Must be a citizen of United States FORMCHECKBOX Must be a Illinois resident FORMCHECKBOX Must be a Lake County resident FORMCHECKBOX Must be resident of specific city: FORMTEXT ????? FORMCHECKBOX Must be resident of specific zip code: FORMTEXT ?????Fees (check all that apply): FORMCHECKBOX No Fee FORMCHECKBOX Fees vary FORMCHECKBOX Sliding Scale fee $ FORMTEXT ????? to $ FORMTEXT ????? based on FORMTEXT ????? FORMCHECKBOX Set program fee $ FORMTEXT ????? per FORMCHECKBOX Accepts Medicaid FORMCHECKBOX Accepts Medicare FORMCHECKBOX Accepts most insurance FORMCHECKBOX Membership fee $ FORMTEXT ????? per FORMTEXT ?????Program Hours: Mon FORMTEXT ????? Tues FORMTEXT ????? Wed FORMTEXT ????? Thurs FORMTEXT ????? Fri FORMTEXT ????? Sat FORMTEXT ????? Sun FORMTEXT ????? FORMCHECKBOX Hours vary Language - Service is available in: FORMCHECKBOX English FORMCHECKBOX Spanish FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Interpreter Services Available for: FORMTEXT ?????PHONE NUMBERSMain Program Phone #: FORMTEXT ?????Other Phone #: FORMTEXT ????? Purpose of other phone (i.e. Afterhours 5pm-8am): FORMTEXT ?????TDD/TTY Phone #: FORMTEXT ?????Agency Name: FORMTEXT ????? Program Name: FORMTEXT ????? Program is offered at this location (“Site A”) Site Name: FORMTEXT ????? e.g. Family Resource Center, Waukegan Site, Zion ClinicPhysical AddressAgency Physical Address: FORMTEXT ?????City, State: FORMTEXT ????? Zip: FORMTEXT ?????Is this office: A confidential location? FORMCHECKBOX Yes / FORMCHECKBOX No Wheelchair accessible? FORMCHECKBOX Yes / FORMCHECKBOX NoMailing Address FORMCHECKBOX Same as above (if mailing address is different, add address below)Agency Mailing Address: FORMTEXT ?????City, State: FORMTEXT ????? Zip: FORMTEXT ?????Program is offered at this location (“Site B”)Site Name: FORMTEXT ????? Physical AddressAgency Physical Address: FORMTEXT ?????City, State: FORMTEXT ????? Zip: FORMTEXT ?????Is this office: A confidential location? FORMCHECKBOX Yes / FORMCHECKBOX No Wheelchair accessible? FORMCHECKBOX Yes / FORMCHECKBOX NoMailing Address FORMCHECKBOX Same as above (if mailing address is different, add address below)Agency Mailing Address: FORMTEXT ?????City, State: FORMTEXT ????? Zip: FORMTEXT ?????Program is offered at this location (“Site C”)Site Name: FORMTEXT ????? Physical AddressAgency Physical Address: FORMTEXT ?????City, State: FORMTEXT ????? Zip: FORMTEXT ?????Is this office: A confidential location? FORMCHECKBOX Yes / FORMCHECKBOX No Wheelchair accessible? FORMCHECKBOX Yes / FORMCHECKBOX NoMailing Address FORMCHECKBOX Same as above (if mailing address is different, add address below)Agency Mailing Address: FORMTEXT ?????City, State: FORMTEXT ????? Zip: FORMTEXT ?????** Add information for additional physical locations as needed. SUBMITTED BYNAME: FORMTEXT ????? DATE: FORMTEXT ????? TITLE: FORMTEXT ????? EMAIL: FORMTEXT ????? PHONE: FORMTEXT ????? Send the completed application by email to 211LakeCounty@. ................
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