Program Application

Only use this form to add new program if your agency is already in the 211 El Dorado Database. Otherwise, CLICK HERE to submit your agency application. Thank you for having your agency and program listed in the 211 El Dorado database.

A field name with an asterisk (*) indicates a required field.

Your Name*

Your Email Address*

Your Agency Name* (in 211 El Dorado database)

New 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