| Read the following
instructions very carefully:
1. Every agency/organization/school should
completely fill out the Agency/Program
Information Form. (both sections 1 and 2)
2. Agencies that administer more than one (1)
program should make copies of the program
information section (section 2) and fill out a
separate form for each of your agencies
programs.
(For example, if your
agency/school/organization administers six
different programs, a separate program
information form (section 2) needs to be
completed for each of the six programs).
Section 1
Agency Information
AGENCY:
Enter the name of your agency. Refer to the
larger system under which your program operates
such as; Beaufort County Department of Social
Services.
AGENCY ADDRESS INFORMATION:
Enter your complete street address and mailing
address (if different from street address).
AKA/ACRONYM:
Enter any acronyms/other name used to describe
your agency such as; DSS, OCIM, JOCCA, etc.
PERSON IN CHARGE:
Enter the name of the individual(s) who are in
charge of the agency/organization.
TITLE:
Enter the title of the individual(s) who are in
charge of the agency/organization.
AGENCY TYPE:
Enter whether your agency is a federal, county,
state, non-profit, municipality, or private
enterprise. Please check all the categories that
apply.
AGENCY PHONE NUMBERS:
Enter the phone numbers for your
agency/organization.
DAYS AND HOURS OF OPERATION:
Enter the days and hours of operation for your
agency/organization.
AGENCY DESCRIPTION:
Enter the mission or a brief summary of your
agency. You may attach a brochure or pamphlet, but
please complete this section.
ACCESSIBILITY:
Check all boxes that apply to your
agency/organization.
DEFINE YOUR SERVICE AREAS:
Town/city only, Beaufort and Pitt, statewide,
etc.
FUNDING SOURCES:
List funding sources for your
agency/organization: United Way, fees,
governmental, contributions, grants, etc.
DIRECTIONS TO AGENCY:
Describe the best way to get to your service
location. Include landmarks, surroundings,
streets, etc. If your location is on a bus route,
please indicate which one.
Section 2
Program Information
Remember: For agencies with more than one
program, please make copies of the Program
Information section and fill out a separate
form for each of your agency’s programs.
PROGRAM:
Enter the complete name of your specific
program or service. For each program use a
separate program information form.
PROGRAM ADDRESS INFORMATION:
Enter your complete street address.
GEOGRAPHIC SEARCH AREA/COUNTY LOCATION:
County that your program is located.
PROGRAM MAILING ADDRESS:
Enter mailing address if different from street
address (optional).
AKA/ACRONYM:
Enter any acronyms used to describe your agency
such as DSS, OCIM, JOCCA, etc.
SHORT DESCRIPTION (optional):
One line description of service program.
PROGRAM PHONE:
Enter your office telephone number, a secondary
number, 800 number, 24 hours a day, National
Affiliation, TDD number, fax number, e-mail
address.
DAYS AND HOURS OF OPERATION:
Enter the days and hours of operation for this
program, if different from the agency’s days and
hours of operation.
PROGRAM DESCRIPTION:
Enter the mission or a brief summary of your
agency/organization. You may attach a brochure or
pamphlet, but please complete this section.
KEYWORDS:
Indicate several index words that should be
used to search for your program. See list on page
2, but please use the terms you need, and/or
words associated with the service provided.
PERSON IN CHARGE:
Enter the name of the individual(s) who are in
charge of the agency/organization.
TITLE:
Enter the title of the individual(s) who are in
charge of the agency/organization.
ELIGIBILITY:
Describe the major eligibility requirements
that clients must meet to obtain your services.
PROGRAM FEES:
Enter a brief description of your program fees,
if applicable.
INTAKE PROCEDURES:
Enter any documentation needed to apply for
services.
LANGUAGES:
List languages spoken by your staff.
SERVICE AREAS:
Williamston only, Beaufort and Pitt,
statewide, etc.
TARGET POPULATION:
Enter the target population your program serves
such as: age, gender, ethnicity, single parents,
etc.
DIRECTIONS TO PROGRAM:
Describe the best way to get to your service
location. Include landmarks, surrounding, streets,
etc. If your location is on a bus route, please
indicate which one.
ACCESSIBILITY:
Check all the categories that apply.
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