2-1-1 HelpLine Non-Profit Listing Form

As you can see, we make a distinction between the agency or organization and its programs. For “Program” you may also think “Division” or “Department’, depending upon how the agency is organized. In many cases the organization and the program are one and the same. If that is true for you, or if there are other parts of the application that do not apply, you may leave those areas blank.

Non-Profit Listing Form
Your Information:
Name
Title
Email
Phone Number


Basic Agency Information:
Use this section to describe the administrative unit, NOT the individual program information. Program Information will be entered later.


Agency Name
Also Known As/AKA
Agency Address:
Street
Apartment/Suite
City
State
Zip Code

Phone Number

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Click Here If You Would Like To Enter More Detailed Agency Information.


Program Information:
Use this section to describe the program. Submit a new form for each program you would like to add. Agency information (except for name) needs to be filled out the first time only.



Program Name
Also Known As/AKA
Address:
Street
Apartment/Suite
City
State
Zip Code

Mailing Address:	Check Here if Same as Above
Street
Apartment/Suite
City
State
Zip Code


	Phone Number(s)	Phone Notes
Main Number
Fax
Toll Free
Additional Number
Additional Number


E-Mail Address
Website Address
Hours
Person In Charge
Title


Please Check the Appropriate Box Describing the Type of Business:
	Governmental (city)	Private, non-profit
	Governmental (County)	Private, for profit
	Governmental (State)	Private Practice
	Governmental (Federal)	Religious Affiliation
	Other (please specify)

Federal I.D.# (if applicable)


Areas Served By Your Program (check all that apply):

	Santa Barbara	Lompoc Valley
	Santa Ynez Valley	Santa Maria Valley

Please Describe All That Apply
Average Unduplicated Clients in a 30 Day Period
Ages Served:
Languages Spoken (including TTD)
If this is a Seasonal Program, enter active months
Eligibility Restrictions/Requirements
Fees
Intake Procedure

Mark all that apply:
	Handicapped Accessible	Scholarships Available
	Accommodates/Special Needs	Continuing Education
	Waiting List	Case Management
	Sliding Scale	Early Intervention Assessment
	Accept Medi-cal/MediCare	Employment Opportunities
	Provides Public Transportation Information	Provides Transportation

Please use the space below to enter suggested keywords you wish to be listed under.

Program Description: Please describe completely, but briefly, what services you offer.

Please check all information to be sure it is correct before clicking the submit button.

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