Community Resource Database Agency/Organization Profile

Community Resource Database Agency/Organization Profile

May-14

This is the first of three profiles or forms required for inclusion in the 2-1-1 Brevard Community Resource Database. This profile is used to record general information about the main office or headquarters of your organization and only needs to be completed once. A Site Profile must be completed for each site or location where services are offered and a Service Profile must be completed for each service offered. Each service profile includes a list of the sites where the individual service is offered.

Please complete this Agency Profile in its entirety and submit with the completed Site and Service Profiles either by mail, fax or email to:

2-1-1 Brevard, Inc. Fax: 321-631-9291 Email:

PO Box 561627

Rockledge, FL 32956

Agency General Information

Agency Legal Name: Enter legal name. Other Name: Enter alternate name. ☐DBA ☐ AKA

☐ Include in Online Database

Street Address Click here to physical address. Is this address confidential? ☐ Yes ☐ No

Mailing Address (if different): Enter mailing address.

Do you operate from multiple sites/locations? ☐ Yes ☐ No

If yes, # of sites serving Brevard County: Total number of sites where services are offered

Contact Information

The following will be shared by Helpline Specialists or in the online database:

Primary Phone Numbers: Phone number. ☐ Admin ☐Program ☐Hotline ☐Other: e.g., “Billing”

Phone number. ☐ Admin ☐Program ☐Hotline ☐Other: e.g., “Billing”

Phone number. ☐ Admin ☐Program ☐Hotline ☐Other: e.g., “Billing”.

Fax Number: Enter fax number.

Website Address: Enter web address.

Agency Email: Enter email address to be shared, e.g. “”

Please provide contact information for 2-1-1 Brevard Community Resource Database confirmations and updates. Only the Agency Director name and title will be viewable to website users.

Agency/Organization Director Name: Director’s Name. Title: Director’s Title.

Email: Director’s email address.

Agency/Organization Contact Name: Enter alternate contact name. Title: Enter contact title.

Email: Contact email address

Agency/Organization Description

Please give a general statement of the mission or function of this agency as a whole.

Mission statement or brief description of organization.

~ Continued on following page ~

Days and Hours of Operation:

Legal Status

☐ Nonprofit – Incorporated ☐ Nonprofit – Unincorporated IRS 501(c) Designation: Choose an item.

☐ Government- City/Town ☐ Government – County ☐ Government – State ☐ Government - Federal

☐ Faith Based ☐ For Profit ☐ Other, please describe: Click here to enter text.

Federal Tax ID: Enter FEIN. Date Incorporated: Click here to enter a date.

Funded By (please select all that apply):

☐ City ☐ County ☐ State ☐ Federal

☐ United Way ☐ Independent Fund Raising ☐ Fees

☐ Grants ☐ Donations ☐ Other Click here to enter text.

Accessibility (Please select all that apply)

☐ Wheelchair accessible ☐ Assistance for visually impaired

☐ Assistance for deaf/hearing impaired

Other/Additional Info: Click here to enter text

Accessible by public transportation? ☐ Yes (please list ex. Bus stop #) Bus route/stop ☐ No

Person Completing This Form

Name: Enter name. Phone: Enter phone #/ext. Email: Enter email address.

Date completed: Click here to enter a date.