Agency Application Thank you for your interest in having your agency listed in the 211 El Dorado database. If your agency is new to the 211 El Dorado database, please use the form below to submit your application. A field name with an asterisk (*) indicates a required field. Does your organization provide services that are appropriate for inclusion in the 211 database, based on the 211 El Dorado County Inclusion/Exclusion Policy? YesNo Have you been in operation for at least six months?YesNo Your Name* Your Email Address* Agency Information Agency Name* Agency Description* (describe your agency in one or two sentences) e.g. Nonprofit organization focused on supporting low-income families in El Dorado County. Agency Type* —Not-for-profit (incorporated)Not-for-profit (not incorporated)Government – FederalGovernment – StateGovernment – CountyGovernment – CityFaith-basedMembershipSpecial DistrictPrivate PracticeFor-profit/Commercial Agency Website Agency General Email (for public use) Physical Address* Is this location wheelchair accessible?* YesNo Is this location confidential?* YesNo Mailing Address* Administration Office Hours* Agency General Phone Number* TDD/TTY Number (if any) Agency Primary Contact Information (The best person for 211 to contact with questions about your service or to update the 211 record.) Agency Primary Contact Name* Agency Primary Contact Title* Agency Primary Contact Email* Agency Primary Contact Phone Number* Agency Senior Executive Information (i.e. Organization Executive Director/CEO/President) Senior Contact Name Senior Contact Title Senior Contact Email Senior Contact Phone Number Program Information Program Name* Program Description* (maximum of 100 words) (e.g. Offers parenting skill classes to parents struggling with managing misbehavior of their children at home or school.) Program Residency Requirement* —No residency requirementMust be a citizen of the United StatesMust be a California residentMust be an El Dorado County residentMust be a resident of a specific city-explain through program Eligibility belowMust be a resident of a specific zip code-explain through program Eligibility below Program Eligibility* Language Offered* EnglishSpanishOtherInterpreter Services Available Other languages (if choose “Other” in the previous question) Program Fees* No feeFees vary based on incomeFees vary based on servicesSliding scale fee based on incomeSet program feeAccepts Medi-CalAccepts MedicareAccepts most insuranceMembership fee Fee information (explain fee range for sliding scale, fees vary, set program fee, membership fee, etc.) Program Intake Procedure* —Visit during program hoursCall or visitCall for an appointmentCall for intakeCall to applyReferral required-provide additional notes belowOther-provide additional notes below Additional notes on Intake Procedure (e.g. Clients must be referred by a school counselor.) Document Required at Intake* (e.g. ID, SSC, Proof of Income, etc.) Program Website Program Hours* Program Phone Number 1* (required) and phone description (e.g. 530-111-1111 Main Number) Program Phone Number 2 (if any) and phone description (e.g. 530-111-2222 Placerville Office) Program Phone Number 3 (if any) and phone description TDD/TTY Number (if any) Program Physical Address 1* (required) where the service is offered Is this location wheelchair accessible?* YesNo Is this location confidential?* YesNo Program Physical Address 2 (if any) where the service is offered Is this location wheelchair accessible? YesNo Is this location confidential? YesNo Program Physical Address 3 (if any) where the service is offered Is this location wheelchair accessible? YesNo Is this location confidential? YesNo Program Mailing Address* Additional Information If you do not hear from us within 5 business days after submitting your application, please contact us at email@example.com. Thank you.To provide information about another program, CLICK HERE after you submitted the Agency Application. Thank you.