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

PLEASE check the appropriate categories below for your service:

Adoption	Adult Day Care	Aids/hiv
Alzheimer's Care	Animal Shelters	Assisted Living
Caregivers	Children's Day Care	Children's Services
Community Needs	Critical Illness	Dental Care
Disabilities	Disaster Relief	Divorce
Education	Employment	Family
Fire Departments	Free Clinics	Gambling Issues
Health Issues	Hearing Impairment	Home Health Care
Home Repairs	Homelessness	Hospice
Hospitals	Hotlines	Housing
Immediate Need	Insurance	Juvenile Justice
Languages	Legal Issues	Licenses
Marriage	Medical Treatment & Supplies	Medicare/medicaid
Medications	Parenting	Poison Control
Pregnancy Issues/care	Prison Ministry	Rape & Sexual Assault
Recreational Therapy	Residential Programs	Runaways
Seniors	Shelter	Singles Groups
Smoking Issues	Social Security	Stds
Substance Abuse	Support Group	Teen Issues
Thrift Shops	Transportation	Veterans Services
Victim's Assistance	Vision	Vocational
Weight Loss	Women's Programs

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!