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Casa Hispana Interagency Partner Info
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Agency Information
Agency Name *
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Contact Person *
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Contact Person Email *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Telephone *
Your answer
Your answer
Website *
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Logo - will you email us your logo?
Since you are not signing into Google, you are not able to upload your logo directly into the form. Please send us an email with your logo; preferably a high resolution/ SVG image and transparent background would be best.
Area of Service *
Please specify the geographical area of service of your organization
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Client eligibility criteria *
Please specify any elgibility criteria the client/ family must meet to receive services or participate in programs of your organization.
Your answer
Services/ Community Programs *
Please provide a list an explanation of the services you offer and programs ran by your organization to serve the community.
Your answer
Services/ Community Programs for Hispanics *
Provide a list and explanation of services/ programs offered to the Hispanic community and/or in Spanish
Your answer
Organization has a bilingual English-Spanish staff to provide direct customer service to Spanish-only speaking clients *
Hours of operation *
Please provide your hours of operation by selecting your "Opening" and "Closing" hours per day of the week. If you are closed on a specific day, select "Closed". You may need to scroll left-right to access the hours. Just select the time when you open and the time when you close (only needed two choices per day of the week, unless you are closed).
06:00 AM
06:30 AM
07:00 AM
07:30 AM
08:00 AM
08:30 AM
09:00 AM
09:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
01:00 PM
01:30 PM
02:00 PM
02:30 PM
03:00 PM
03:30 PM
04:00 PM
04:30 PM
05:00 PM
05:30 PM
06:00 PM
06:30 PM
07:00 PM
Other info regarding hours of operation
Your answer
Type of Organization *
Select all that apply
Documents: brochures, forms, etc. - Will you email us other documents?
Since you are not signing into Google, you are not able to upload your documents directly into the form. Please send us an email with any program description brochures, intake forms, and other documents about your organization and services you offer which would be of service to member of the Hispanic community.
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