2-1-1 Orange County

Agency Profile

1.  Agency Name: (Legal name of the agency):

2.  AKA Names: Other names the agency may be known as (i.e., former names, acronyms, etc.):

3.  Email/Website Information: Your agency’s general email address and/or website address:

Email: Website:

4.  Physical Address: Physical location of the agency (Please use Program & Services Profile for additional locations):

Street / City / Zip

Is this address confidential? Yes No

Is this address handicap accessible? Yes No

Major cross street(s):

5.  Mailing Address: (If different from the physical location, i.e. P.O. Box)

Street / City / Zip

6.  Phone Numbers: Please list and identify all phone numbers used by the agency for the business office, program intake, emergencies, fax, after hours, hotline, TDD/TTY, etc.

Referral phone: ( ) / Toll Free: ()
Administration: () / Fax: ()
Other: ()

7.  Hours:

Agency Hours
Monday / to
Tuesday / to
Wednesday / to
Thursday / to
Friday / to
Saturday / to
Sunday / to

8.  Executive Contact: (Executive Director, Branch Director, etc.):

Name: Title:

Phone: Email:

9.  Primary Contact: (Person to contact for verification of agency and/or program information)

Name: Title:

Phone: Email:

10.  Agency Type: Please indicate the legal status of your agency:

Government

Nonprofit (private): Please indicate your agency’s non-profit classification (e.g., 501(c)(3))

Faith Based Please provide copy of letter from IRS verifying nonprofit status.

Other

Private for Profit

11.  Mission Statement:

12.  Agency Description: Please provide a brief summary description of your services:

13.  Additional Information:

Do you have brochures/newsletters about your agency’s programs? Yes No

If yes, please include brochure when returning this information.

Do we have permission to use your agency program information on:

2-1-1 or Help Me Grow Brochures? Yes No

2-1-1 or Help Me Grow Websites? Yes No

Completed by: Deanna Parga Date:

Title: Community Liaison Phone: 714.939.7141

Please mail or fax completed form to:

Help Me Grow—Orange County

1915 W. Orangewood Avenue, Suite 303

Orange, CA 92868

Phone #: 714-939-7122 Fax #: 714-939-6199

4/15/2009 1