Lake County Community Resource Guide

Agency Information Form

Your agency provides valuable services to the residents of Lake County. In an effort to provide information and referral resources to the residents of Lake County, we are updating our information. Would you please take a minute to complete the following information about each program your agency administers? Thank you!

Organization/Agency Name (required)
Is this Org/Agency a Non-Profit?	No Yes
Program Name
Phone #
Scope of Services Provided Be specific!	characters remaining
Contact Name and Title (required)
email (required)
Fax #
County (or "National")
Address
City
State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS GU NI PR VI
ZIP Code
Website
Hours of operation (i.e., "M-F, 8:00am-5:00pm")
Ages served
Fee/Cost to Client
What does your agency need from a client in order to provide services? (i.e., Picture ID, Passport, etc.)	Characters remaining
Languages spoken
What proven researched-based programs, models, or strategies are utilized in the services you provide?	Characters remaining
What resources is your agency in need of? Example: Volunteers, etc.	Characters remaining

The Safe Climate Coalition of Lake County, Inc. reserves the right to edit or exclude any submissions made.

Please submit your completed form,

 or print it out and either...

fax to: Debi’s attention at 352.742.6466, or

mail to: Debi’s attention, Safe Climate Coalition, P.O. Box 64, Yalaha FL 34797.

If you have any questions, please don’t hesitate to call me at 352.408.2009. Thank you!