Parent Agency (if applicable):


For Clubs and Community Groups:
Presiding Officer or Member contact:

Title:


Address (if different from above):

Phone Number (if different from above):


For each program or branch office you operate, please provide the following:
Service(s) Provided:

Hours/Meetings Times:

Start Date/Season (if applicable):

Fees:

Eligibility Requirements:

Intake Procedure:

Geographic Service Area:

Major Source of Funding:

Email Address:

Do You Currently Have a Website?: Yes No

Web Site Address:

To improve our services to special populations, we are collecting specific information about ways people can access local programs. Please answer the following questions as well.

Serving People With Physical Disabilities
Is reserved handicapped parking available:
Yes No N/A
Is your building physically accessible: (Free from steps, free from curbs, doorways and hallways at least 36" wide?)
Yes No N/A
Do restrooms accommodate wheelchairs?
Yes No N/A
Do elevators accommodate wheelchairs?
Yes No N/A

Serving People With Speech/Hearing Disabilities
Do you have a TDD/TTY (Text Type) number?
Yes No N/A If yes, the number is:
Do you have American Sign Language interpreters available?
Yes No N/A

Serving People With Visual Disabilities
Do you provide service via materials in Braille?
Yes No N/A
Do you provide service via Large Print materials?
Yes No N/A
Do you provide service via spoken word recordings?
Yes No N/A
Do you have someone available to read materials one-on-one?
Yes No N/A

Serving People Outside Local Calling Area
Do you have a toll-free/1-800 number?
Yes No N/A If yes, the number is:
Do you accept collect calls from the public?
Yes No N/A

Currently, Clubs/Organizations/Agencies are listed under the following 14 keywords with subcategories on the Lincoln County Family and Youth Resource Directory Website.

Please choose the categories and keywords that best describe your organization/agency. There is also an area to list a keyword you would feel best describes the services your club/organization/agency provides.

To select multiple keywords, hold down the 'Ctrl' key on your
keyboard and click each keyword.
Choose for: Adult
a -Activities -Churches -Clubs/Organizations -Counseling Services -Crisis Centers -Entertainment/Recreation -Food Services -Government -Library -Programs -Veterans                                                                         

Choose for: Alcohol/Drug
a -Counseling Services -Crisis Centers -Employment Assist. Programs -Support Groups                                                                         

Choose for: Career/Job
a -Job Services -Social Services                                                                         

Choose for: Children
a -Activities -Child Care Providers -Church Groups -Preschool Providers -Programs -Resources                                                                         

Choose for: Education
a -Information/Referral Services -Libraries -Parochial Schools -Preschools -Private Schools -Public Schools -Special Education Programs -Technical Schools -Universities -UW-Extension -Scholarships                                                                         

Choose for: Emergency
a -Counseling Services -Crisis Centers -Emergency Services -Healthcare -Information/Referral Services -Job Services -National Hotlines -Social Services                                                                         

Choose for: Financial
a -Financial Aid -Financial Counseling -Food Services -Fuel Assistance -Scholarships -Supplemental Income                                                                         

Choose for: Health Care
a -Chiropractors -Clinics -Dental -Eye Care -Health Department -Home Care -Hospice -Hospitals -Medical/Financial Assistance -Nursing Homes -Nutrition -Pharmacy -Podiatry -Social Services -Support Groups                                                                         

Choose for: Housing
a -Elderly -Financial Aid -Group Homes -Home Care -Hospice -Low Income -Nursing Homes                                                                         

Choose for: Legal
a -Advocacy -Legal Counseling                                                                         

Choose for: Mental Health
a -Counseling Services -Crisis Centers -Support Groups                                                                         

Choose for: Parenting
a -Adoption Services -Family Resource Centers -Parenting Programs -Resources                                                                         

Choose for: Transportation
a -Private -Public -Specialized                                                                         

Choose for: Youth
a -Activities -Church Groups -Clubs/Organizations -Counseling Services -Crisis Centers -Programs -Support Groups                                                                         

Other Keyword:


Thank you for providing the Lincoln County Family and Youth Resource Directory with your agency's/organization's information. Click the Send button below to submit this information. You will be returned to this form after it has been successfully submitted.