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Request for Inclusion in 2-1-1 Database

For your agency to be included in the Hall County 2-1-1 database, this online survey must be filled out completely and submitted.

Use this form from whenever necessary to update our database as your agency changes. A survey must be submitted for each program offered by your agency. If requested information does not apply to your program, enter “N/A.”

If you would rather download a PDF of this survey and fax or mail it to us, click below. Instructions on submission are in the document.

 Download the inclusion survey here. Or fill out below.

Database Information Request

1. Agency Name
  Physical Address
  City, State, Zip
2. Mailing Address
  Attn.
  Agency Name
  Mailing Address
  City, State, Zip
3. Agency also known as: (optional)
4. Person in charge of agency
  Title
5.
Volunteer Non-Profit For Profit
Private Practice Religious Not Classified
6. The following information is given to callers seeking services. Be sure all information is correct.
  Phone Number Phone Description and/or Contact Person
1.
2.
3.
4.
5.
6.
7. Email Address
8. Website
9. Hours
10. Programs Operated by this agency
11. Describe in detail program and services provided. Use additional sheet of paper if needed.
12. Eligibility criteria
13.

Fees:
  Sliding scale
  Straight fee , no adjustment
  No fee
  Other considerations
14.

Insurance accepted? Yes No

  If yes, what type? private insurance Medicaid Medicare Worker's Comp
15. Intake procedure (check all that apply):
 
phone walk in appointment
written referral referral required by  
16.

Languages:

 
English Spanish Vietnamese
Other:
17.

Counties served (check all that apply):

 
Hall Forsyth Dawson
Banks Franklin Stephens
White Habersham Union
Rabun Lumpkin Towns
Hart other:
18.

Documentation (check all that apply):
 
none picture i.d. social security card
birth certificate proof of residence proof of income
eviction notice utility cut-off notice  
other:
19.

Donations accepted? Yes No   If yes, please specify below.

  clothing:
  food:
  furniture, appliances, household goods:
other:
20.

Person to contact for program/services update:

  Title:
  Dept.:
  Phone:
21.

Transportation:
 
no convenient public transportation program provides transportation
program will arrange transportation program offers home deliveries
  Special conditions (please specify):
22.

Seasonal services offered:

Yes No
  If yes, please check all that apply.
Christmas holiday assistance holiday dinners
holidays school year  
  Seasonal program start date:
  Seasonal program end date:
23.
wheel chair accessible physical address confidential include in directory
disaster response list in HR directory United Way agency
Volunteer form returned Volunteer opportunities (VO) VO: anytime
VO: evening VO: morning VO: weekend
VO: afternoon VO: youth  
24.

If your agency/program will be active during local disaster please specify available resources:

25. May we publish your information on our web site and/or in our directory? Yes No
26.

Do you use Volunteers in your organization?

Yes No
  Can you use community service workers? Yes No
  Can you use Youth Volunteers? Yes No    If yes, what age?
  Job descriptions for Youth Volunteer opportunities:
27.

Hours Volunteers are needed:

 
AM anytime afternoons
PM weekends  
28.

Job descriptions for Volunteer opportunities:

29. Is a Volunteer training program available? Yes No
30.

Commitment asked of Volunteers:
31.

General requirements:

 
Background check Uniform required Drug test
Uniform supplied References Dress code
32. Volunteer coordinator:
     
Name
Title
I verify that the submission of this form constitutes my signature on behalf of my agency and accept all the responsibilities related to it.
Date

United Way 2-1-1 reserves the right to exclude organizations deemed inappropriate for their database.



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P.O. Box 2656
Gainesville, GA 30501		 Designed by Red Clay Interactive