Submit Applications/Updates Via Email Or U.S. Mail

PROGRAM/SERVICE SITE APPLICATION/UPDATE Program Information Please fill out and submit one form per program. Agency Name: Program Name: Is this program commonly known by another name or abbreviation? Program Website/URL (only if different than agency): Program Email Contact: Program Description/Primary Services (use specific keywords search terms such as food, housing, or any additional information about your services that would be helpful for clients and for 211 when making referrals) Maximum of 100 words. How many sites/locations offer your program? If more than one, please fill out a separate application for each. Information that is the same at all locations (i.e. Intake procedure is walk-in at all locations) can be marked as “Same” in each category. Intake Procedure: Telephone Intake Walk-In Call for Appointment Referral Required Required Documentation at Intake: (i.e. ID, SS card, Program eligibility requirements: Proof of Income etc.) Eligibility requirements based on residency (i.e. program only serves residents of a specific city)?

Types of Fees: No Fee Sliding Scale fee $ ______to $ ______based on ______Please call for fee information Program Hours: Monday Tuesday Wednesday Thursday Friday Saturday Sunday What languages is the service available in?

Program Information by Service Site Please fill out and submit one form per site. Program Name: Site Name (This is the name of the physical location. It can be specific – i.e. ABC Family Resource Center – or general – i.e. Oxnard Office) :

Is this physical address a Physical/Street Address: City, State: Zip: confidential location? Yes No PROGRAM/SERVICE SITE APPLICATION/UPDATE Mailing Address Mailing Address: City, State: Zip: Same as above Program /Site phone numbers Main Program Phone #: Other Phone # (if different from Main): Fax #:

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

Is this physical location wheelchair accessible? Yes No

SIGNATURE I AUTHORIZE THE VERIFICATION OF THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE. I UNDERSTAND THAT IN ORDER TO KEEP 211 YOLO’S DATABASE ACCURATE AND UP TO DATE, AGENCIES ARE ASKED TO INFORM 211 YOLO OF CHANGES TO THE AGENCY’S OPERATIONS WITHIN 30 DAYS AND TO PROVIDE CURRENT INFORMATION DURING OUR ANNUAL UPDATE PERIOD. I HAVE READ AND UNDERSTOOD 211 YOLO’S INCLUSION/EXCLUSION POLICY. APPLICATIONS/UPDATES WILL BE PROCESSED WITHIN 7 DAYS OF RECEIPT. PRINT NAME: PHONE:

TITLE: EMAIL:

SUBMIT APPLICATIONS/UPDATES VIA EMAIL OR U.S. MAIL 211 Yolo 25 N. Cottonwood St., Woodland CA, 95695 Phone: (530) 666-8004 Email: [email protected] www.211yolocounty.com