Program Form
-Instructions on how to fill out this form.
Welcome to the Mid-East I&R Program form. Please fill out a separate form for each program or service your agency provides. For each program or service fill out the information below, and send it to us by pressing the Submit button at the bottom. It is usually a good idea to double check the information before submitting the form. Once you have submitted the data, it will take up to one week for the new data to appear on Aginglink.  You can make a copy for yourself selecting print from the file menu.

If you submitted the wrong information or you want to submit an update please send an update on the fields that apply.

If you have any problem submitting the form please email MTabak@mideastcom.org
 
Information on update: Have you previously submitted data for this program?

Yes

No


 

1. Agency Name:
2. Program Name:
3. Physical Address:

City: State: Zip:
4. Mailing Address (if different):

City: State: Zip:
5. Geographic Search Area / County Location: Check all that apply:
 
Beaufort Bertie Herford
Martin Pitt
 
6. AKA/Acronym:
7. Short Description (optional):
8. Program Phone:
Main: National Affiliation:
Secondary: TDD:
800: Fax:
24-Hour Number: E-Mail:
Home Page:
Http://www.		  
9. Days and Hours of Operation:
10. Program Description:
11. Keywords Please enter as many keywords as you like, separated by comma's:
12. Person in Charge:
13. Title:
14. Eligibility
15. Program Fees: (please give the exact amount and briefly explain)
16. Intake Procedure:
17. Languages: spoken by     staff
18. Service Area:
19. Target Population:
20. Directions:
21. Accessibility:
Wheelchair Accessible Sliding Fee Scale
Handicap Parking Accepts Medicare
Parking Near Building Accepts Food Stamps
On Bus Route Accepts Major Credit Cards
Agency Transportation Residence Required
TTY Translator  
Appointment Required
22. Form Completed By:
23. Phone: