Lake County Community Resource Guide

  Agency Information Form

 

Your agency provides valuable services to the residents of Lake County.In an effort to provide information and referral resources to the residents of Lake County, we are updating our information.Would you please take a minute to complete the following information about each program your agency administers?Thank you!

 
Organization/Agency Name (required)

 
Is this Org/Agency a Non-Profit?  
Program Name

 
Phone #

 
Scope of Services Provided
Be specific!


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Contact Name and Title (required)

 
email (required)

 
Fax #

 
County (or "National")

 
Address

 

 
City

 

 
State

 
ZIP Code

 

 
Website

 
Hours of operation (i.e., "M-F, 8:00am-5:00pm")

 
Ages served

 
Fee/Cost to Client

 
What does your agency need from a client in order to provide services? (i.e., Picture ID, Passport, etc.)


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Languages spoken

 

What proven researched-based programs, models, or strategies are utilized in the services you provide?


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What resources is your agency in need of?
Example: Volunteers, etc.


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The Safe Climate Coalition of Lake County, Inc. reserves the right to edit or exclude any submissions made.

 

Please submit your completed form,


 or print it out and either...

fax to: Debiís attention at 888.575.7503, or

 

mail to: Debiís attention, Safe Climate Coalition, P.O. Box 64, Yalaha FL 34797.

 

If you have any questions, please donít hesitate to call me at 352.408.2009.Thank you!