UPCAP : Programs & Services : U.P. 2-1-1 Call Center : Agency Resource Questionnaire

The information requested in this form will be used to refer callers throughout the Upper Peninsula of Michigan who are seeking services and volunteer opportunities in their communities. Your accurate detailed information will better help us refer callers appropriately and efficiently. PLEASE complete the online form below.

Questions? Contact Melissa Kositzky at UPCAP: (906) 786-4701 or simply dial 2-1-1. We appreciate your participation in our database and look forward to referring our clients to your resources.

Official Organization Name *REQUIRED*

If incorporated, list name as it appears in the Articles of Incorporation

Main/Administrative Office

Street Address

City, State, ZIP

Main Number *REQUIRED*

Fax Number

Toll Free Number

TTY or Other Numbers

Please indicate whether a telephone number should be kept confidential from the public.

Administrative Office Hours

Agency/Organization Director

Title

Phone Number

Email Address

Website Address

Contact Person

if different from Director

Title

Phone Number

Email Address

Federal ID Number (optional)

Other/Previous or AKA Organization Name

Is your agency or sites accessible by public transportation

Licenses/Certified/Accredited by

Please list all that apply

General Agency Description/Mission Statement

Site Information

A "Site" is where programs are offered. Please complete this section for EACH Site/Satellite Office. Please complete if you have multiple sites in addition to your Administrative Office.

Questions? Contact Melissa Kositzky at UPCAP Services, Inc.: (906) 786-4701 or simply dial 2-1-1. We appreciate your participation in our database and look forward to referring our clients to your resources.

Official Organization Name *REQUIRED*

If incorporated, list name as it appears in the Articles of Incorporation

Site Name *REQUIRED*

Street Address *REQUIRED*

City, State, Zip *REQUIRED*

Mailing Address

if different from Street Address

City, State, Zip

Main Number *REQUIRED*

Fax Number

Toll Free Number

TTY or Other Numbers

Please indicate whether a telephone number should be kept confidential from the public.

Site Office Hours

Site Director

Title

Phone Number

Site Area Served

Site Hours

Is your agency or sites accessible by public transportation

Confidential/Unpublished Information

Please include any special instructions of information that would remain unpublished but available to our call center staff when screening calls to make the most appropriate referrals.

Program/Service Information

Program/Service Name & Location *REQUIRED*

Program Contact Person *REQUIRED*

Telephone Number *REQUIRED*

Services Offered *REQUIRED*

Program Area Served *REQUIRED*

Hours/Days that Services are available

Please clarify

Description of Program Services *REQUIRED*

Application Procedure *REQUIRED*

Appointment required? Call first? Walk-in? Referral required (from whom)?

Eligibility *REQUIRED*

Age, income, residency, etc

Documents Required *REQUIRED*

What types of information should a client bring to their first visit?

Fees & Payment Information *REQUIRED*

Are pay plans available? What insurance plans are accepted?

Is the program seasonal or offered year round? *REQUIRED*

If seasonal, please list dates available

Form Completion Information

Form completed by *REQUIRED*

Title *REQUIRED*

Phone Number *REQUIRED*

Date Completed *REQUIRED*

Your e-mail Address *REQUIRED*

UPCAP

Providing guidance and support to U.P. residents since 1961

Programs & Services

Agency Resource Questionnaire

Agency Resource Questionnaire

Main/Administrative Office

Site Information

Program/Service Information

Form Completion Information