| Organization
Name:
Program
Name:
Alternate
Name: (Acronym or Common
Name)
Address
(mailing):
Street:
City:
State:
Zip:
Physical Address
(if different from physical address):
Street:
City:
State:
Zip:
Phone
Number:
[ex:
410-555-6666]
After
Hours Number:
[ex:
410-555-6666]
TTD
or TTY:
Fax
Number:
[ex:
410-555-6666]
Contact
Person:
Direct
Phone Number or Extension:
Email
Address:
Hours
of Operation:
Hours
for Intake:
Target
Group (Disabilities Served):
Ages
Served:
Geographic
Area Served:
Eligibility
Requirements:
Handicapped
Accommodation:
Wait
Time/List:
Fees:
Income
Guidelines:
Program
Description:
Person
Completing Information:
Date
Information Completed:
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