KAN-I HELP Intake Form
Thank you for helping us expand our agency database. Our goal is to help citizens connect with the resources and services that they need to succeed. If you have any questions regarding the information intake process, please contact Mariah Garratt @ 708-573-9762.
What is the name of your organization? *
Your answer
Agency Type (Select all that apply) *
Required
Territory Your Organization Serves
Languages Spoken (If any other than English)
Your answer
General Description of your Organization (1-2 sentences) *
Your answer
Address (If multiple, please label location titles)
Your answer
Organization's Main Phone Number
Your answer
Organization's Secondary Phone Number (If number belongs to a separate addresses, please label accordingly)
Your answer
Toll-Free Phone (If applicable)
Your answer
Agency Email
Your answer
Website
Your answer
REQUIRED: What services does this organization offer? (Please label each service name and a brief 2-3 sentence description) *
Your answer
Organization's Hours of Availability
Your answer
Contact Person: Name and Title (Please note if you would like for this contact to be listed OR unlisted - used for bi-annual email updates.) *
Your answer
Contact Person's Phone Number and/or Email Address *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Kan-I Help. Report Abuse