2-1-1 NorCal Listing Application
211 NorCal listing application to list local resources in the database, for referrals or request changes in Shasta, Siskiyou, and Tehama Counties. For more information, call or email Senior Program Specialist - Certified Database Curator - Amy Forrest (530) 356-1343, aforrest@norcalunitedway.org.
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Agency Name: *
AKA (former or popular names): *
Description of Agency (brief overview of services) *
Agency Physical Address: *
Agency Mailing Address: *
Agency Phone Number: *
Agency Website: *
Agency Contact for 211 Updates (please provide name, best phone number, and email): *
Agency Type (legal status): *
Tax Status: *
Federal Employer ID# (EIN): *
Year Incorporated: *
Agency Days & Hours of Operation: *
Application is for the following county: (select all that apply) *
Program Name & Description of Services (in detail): *if you have more than one program to list, please list each program and their descriptions below* *
Eligibility requirements? (age, income based, etc.) *
Does your agency provide additional services to those affected by Public Safety Shutoff (PSPS) events or Disaster events? *
Street Address (of program - if different from agency):
ADA Accessibility (select all that apply): *
Transportation: *
Eligibility Requirements (age, gender, income eligibility, etc.): *
Languages Offered: *
Program Fees: *
Types of Insurance Accepted: *
Application Process: *
Required Documents: *
Typical Wait Time: *
Area Served (cities, counties, states, national, etc.): *
Program Contact Person: *
Share contact info on 211 website? *
Volunteer Opportunities (include eligibility and application process):
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