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Thank you for your interest in joining the 211 Lake County directory. Complete the form below to request that your organization and programs be reviewed for inclusion. Accurate, up-to-date information helps our 211 navigators connect community members with the most appropriate services and resources.

This form includes two sections:

1. Agency Information – General information about your organization.

2. Program Information – Information about each program or service your organization provides.

Please complete one Program Information section for each program you would like listed.

Please provide the most accurate and up to date information to be reflected in the 211 database and to be used by 211 navigators to provide accurate referrals.

SERVICE PROVIDER APPLICATION/UPDATE FOR UNITED WAY OF LAKE COUNTY 211

AGENCY PROFILE INFORMATION

Based on the United Way of Lake County Inclusion/Exclusion Policy, my organization provides services that are appropriate for inclusion in the 211 database.

Review the Inclusion Guidelines

Has your Agency been in operation for at least six months?

General Agency Information

* Is your agency also commonly known by another name or abbreviation:

* Parent Agency (If legally part of another organization):

* Agency Description (describe your agency in one or two sentences):

* If Yes, which level?

Agency Contact Information

Agency Email: (for general questions from the public)

* Agency Physical Address:

A confidential location?

Wheelchair accessible?

Mailing Address Same as above (if mailing address is different, add address below)

Agency Mailing Address:

Administration Office Hours:

What holidays does your agency close for?

Agency General Information Phone #:

Agency Senior Executive

Agency Primary Contact for 211

* To remain listed in the 211 database, my agency agrees to continuously provide timely updates to 211 regarding any changes to programs, services, eligibility requirements, contact information, hours of operation, or other relevant information, ensuring agency program information remains up to date.

* This person will receive the 211 annual update request to confirm and/or update your agency’s information in the 211 database and will be contacted if there are questions about your agency’s information in the 211 database. To ensure the accuracy of referrals, agencies that do not respond to the annual update will be subject to removal.

PROGRAM INFORMATION (Please submit one Program Information section per program)

Mailing Address Program address same as above (if program is held at the agency address)

Agency Mailing Address:

Is this program commonly known by another name or abbreviation?

Program Website/URL:

Program Manager Name:

Program Email Contact:

Program Description/Primary Services Maximum of 100 words. (e.g. Offers parenting skill classes to parents struggling with managing misbehavior of their children at home or school)

* Documentation Required at Intake (i.e. ID, SS card, Proof of Income etc.) Please specify:

* Program eligibility requirements:

* Other: (e.g. Must be parents with children under 18 years old)

* Residency requirement:

* Must be resident of specific zip code:

* Fees (check all that apply):

* Sliding scale fee (add from and to):

Accepts most insurance

Language - Service is available in:

Interpreter Services Available for:

Purpose of other phone (i.e. Afterhours 5pm-8am):

Mailing Address Program Address Same as above (if program is held at the agency address)

Agency Mailing Address:

Is this program commonly known by another name or abbreviation?

Program Website/URL:

Program Manager Name:

Program Email Contact:

Program Description/Primary Services Maximum of 100 words. e.g. Offers parenting skill classes to parents struggling with managing misbehavior of their children at home or school.

* Documentation Required at Intake (i.e. ID, SS card, Proof of Income etc.) Please specify:

* Program eligibility requirements:

* Residency requirement:

* Must be resident of specific zip code:

* Fees (check all that apply):

* Sliding scale fee (add from and to):

* Set program fee $:

Accepts most insurance

Language-Service is available in:

Interpreter Services Available for:

Purpose of other phone (i.e. Afterhours 5pm-8am):

Mailing Address Program Address Same as above (if program is held at the agency address)

Agency Mailing Address:

Is this program commonly known by another name or abbreviation?

Program Website/URL:

Program Manager Name:

Program Email Contact:

Program Description/Primary Services Maximum of 100 words. e.g. Offers parenting skill classes to parents struggling with managing misbehavior of their children at home or school.

* Documentation Required at Intake (i.e. ID, SS card, Proof of Income etc.) Please specify:

* Program eligibility requirements:

* Residency requirement:

* Must be resident of specific zip code:

* Fees (check all that apply):

* Sliding scale fee (add from and to):

* Set program fee $:

Accepts most insurance

Language-Service is available in:

Interpreter Services Available for:

Purpose of other phone (i.e. Afterhours 5pm-8am):

If you have more than four programs, please check this box and a member of our 211 team will reach out to you. If you have more than four programs check this box and one of our 211 team will reach out to you.

United is the way we create lasting change

Apply to list your organization in 211 Lake County

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