Date

MM

DD

YYYY

Organization Physical Address *

If physical location is confidential Please provide PO Box mailing address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Organization Phone *

(###)

###

####

CEO/President/Exec Director Name *

First Name

Last Name

CEO/President/Exec Director *

If different from the organization phone

(###)

###

####

Type of Organization *

501(c)

Government

Church

For profit

Other

Please provide us with the name and number of a contact person we can call for additional information. *

(###)

###

####

Is this site accessible to the disabled? *

Yes

No

Is this site accessible to wheelchairs? *

Yes

No

Languages *

English

Spanish

Other

Is this the only site your organization operates?

Yes

No

Are the program services listed at other sites? *

Yes

No

Are there fees for your program services *

No fee

Accept Medicare

Accept Medicaid

Flat Fee

Based on incomed and family size

Donation accepted

Call for information

How to apply for services *

Call for application

Call for appointment

Call for information

Walk-ins accepted

Other

Documents required *

None

Valid ID

Proof of address

Utility bill

Proof of income

Social security card

Call for information

Other

Languages other than English *

ASL

Spanish

Other