211 RESOURCE INFORMATION FORM
ORGANIZATION NAME:
PROGRAM NAME Please fill out this form separately per program your organization offers if applicable:
Also Known As (AKA) Please include acronyms, former names, and other names by which your organization/program is known:
ADDRESS:
CITYSTATE ZIP CODE
CONFIDENTIAL (Is this addresspublic information?) Yes No
MAILING ADDRESS Enter only if different from address above:
STREET ADDRESS
CITY STATE ZIP CODE
CONFIDENTIAL (Is this address public information?) Yes No
MAIN PHONE:MAIN E-MAIL: MAIN FAX:
MAIN WEBSITE:
SERVICE DESCRIPTION Please describe the services provided by your program. Use language that the general public would understand and eliminate as much technical jargon as possible. If more space is needed, please attach an additional sheet of paper. Note: Aloha United Way 211 reserves the right to edit for clarity and consistency.
HOURS OF OPERATION:
ELIGIBILITYREQUIREMENTS Please specify in the field below of any requirements clients must fulfill to receive services from your program. If there are no eligibility requirements, please check “Not limited”. Check mark any medical insurance your organization accepts. If you do not accept any medical insurance or it is not applicable to your program, please check “N/A”.
Not limited. CHAMPUSHMSAKaiser Plan
Medicaid Medicare Quest N/A
Other (Please list):
INTAKE PROCEDURE Please mark any of the following:
Walk-in Appointment required Written application Phone
Screening interview Wait list for Referral required by
Other (describe):
SERVICE AREA Check the island or community where clients must live to receive your services:
Statewide Lanai KauaiHilo
United States Niihau Molokai Kona
Oahu Maui Hawaii (Big Island)
LANGUAGES:
Can interpretive services be arranged by your organization?
FEES Please mark any of the following:
FreeSliding scale fee based on income Flat fee amount:
Membership dues per Other:
ACCESSIBILITY Are your organization’s facilities accessible to the disabled?
Please mark one of the following: “Barrier-free for disabled” “Not barrier-free for disabled”
TRANSPORTATION Does your agency provide transportation to clients?
Please mark one of the following: “Rides provided by organization” “Rides not provided by organization”
ADDITIONAL INFORMATION Include any information you wish to make known about your organization that does not fall into the above listed categories if applicable.
ORGANIZATION TYPE Indicate how your organization is categorized. Please mark any of the following:
Non-profit County State
Federal Military For-profit
Foreign government Faith-based Informal Organization
UPDATE CONTACT(Person Aloha United Way 211 can contact regardingthe updated information):
Name: Title:
Phone: Fax: E-mail:
Regarding questions or concerns about adding or updating your organization/program information with 211, please call: (808) 543-2262. Submit this form via e-mail or fax to (808)599-7712. You may also mail us at our address:
Aloha United Way 211
Attn: 211 Program Assistant
200 N. Vineyard Blvd., Suite 700
Honolulu, HI 96817
Resource Information Form Rev. 09/2013
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