Service Provider Identification Tool
Service Category *
Please select the primary category of services provided for youth.
Service Provider Name *
Please list the name as you would like it displayed on the map.
Your answer
Description of Providers Services
Please provide 100 word or less description of location relative to youth experience.
Your answer
Provide the address of the location where the point should be displayed on the map. Please note that if a service has multiple locations, an individual form should be completed for each location. *
Standard Address Field Only Ex. 123 Absolute Road, Wake Forest, NC 27555
Your answer
Days and Hours of Operation *
Ex., M,W,F from 10 AM - 2 PM
Your answer
Eligibility Information
Please provide any information regarding restrictions for eligibility for participation.
Your answer
Phone Number *
Ex. (919)555-5555
Your answer
Ages Served *
Ex. Ages 10 - 18
Your answer
Languages available
Provide the list of languages that the organization is prepared to serve.
Your answer
Fee Description *
Please note whether any fees are associated with services or participation.
Your answer
Website URL *
We will link to the organization website. Ex. http://www.asdf.com
Your answer
Image URL *
Please provide an http link to the image you would like to display on the map.
Your answer
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