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).
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.
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.
