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 / ZipIs 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 / Zip6. 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 HoursMonday / 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