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? *
Agency Type (Select all that apply) *
Territory Your Organization Serves
Clear selection
Languages Spoken (If any other than English)
General Description of your Organization (1-2 sentences) *
Address (If multiple, please label location titles)
Organization's Main Phone Number
Organization's Secondary Phone Number (If number belongs to a separate addresses, please label accordingly)
Toll-Free Phone (If applicable)
Agency Email
REQUIRED: What services does this organization offer? (Please label each service name and a brief 2-3 sentence description) *
Organization's Hours of Availability
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.) *
Contact Person's Phone Number and/or Email Address *
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