The YEP Pages Survey

If your organization is already listed in the 2-1-1 Directory, all you need to do to be included in The YEP Pages is submit the form below. If your organization is not currently listed in the 2-1-1 Directory, you must first fill out the initial 2-1-1 Directory listing form found here. Once the initial 2-1-1 listing form is complete, you may add yourself to The YEP Pages by filling out the form below.

The YEP Pages Survey
Your Information:
Name
Title
Email
Phone Number


Agency/Program Information:

Agency Name
Program Name
(Please submit a new form for each program)


Type(s) of Services Offered:

The goal of The YEP Pages is to provide information about specific services your organization provides that could be relevant to educators and schools, as well as the students and families they serve. Please describe how your program's services might meet the needs that teachers and families encounter.



Please indicate the category listings for which your program applies (check all that apply):
	Arts/Science/Libraries/Museums	Recreation/After-School Programs
	Substance Abuse	Child Safety and Protection/Juvenile Justice
	Preschool/Childcare	Parent Education/Family Support
	Mentoring/Scholarships/Career Development	Children's Mental and Physical Health
	Advocates/Assistance for Low Income


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

	Santa Barbara	Lompoc Valley
	Santa Ynez Valley	Santa Maria Valley


Your Program In The Schools:

How might a teacher or school staff person use your program or agency's services? (check all that apply):

	Refer a student to the program	Request handouts for families
	Request handouts for students	Invite us to present information to students
	Refer a parent or caregiver to the program


Service Referrals:

If you provide services to which a teacher might refer students or their families, please indicate the process by which this referral should be made. (check all that apply):

	Student can be given program contact information to access services directly
	Parent or caregiver can be given program contact information to access services directly
	Teacher or school staff person should contact program to make referral


Presentations:

If you provide informational or educational presentations in the schools, please briefly describe the type and content of these presentations:



Grade level(s) to which your program could apply (Check all that apply):
	Kindergarten-2nd	7th-8th
	3rd-4th	9th-10th
	5th-6th	11th-12th


Type of Presentation: (check all that apply):
	Lecture	Performance
	Discussion	Video
	Other



Does your presentation or accompanying curriculum meet California State Content Standards in any of the following subject areas? (check all that apply):
	English Language Arts	Mathematics
	History/Social Science	Science
	Visual and Performing Arts	Physical Education




Presentation Group Size (check all that apply):
	Small Groups	Large Groups	Both


Additional Information:


Presentation length:


If materials are provided with presentations, what is provided?


Is special equipment needed (such as a microphone, podium, TV monitor, etc.)?


Any special seating or room configuration requested?

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

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