A Collaborative effort by the Partnership for Children of Cumberland County
Thank you for your input in this important endeavor. Please complete a survey for each program your organization provides.
Program Name _________________________________________________________________
Formal name of organization_________________________________________________________
Known as______________________________________________________________________
Street Address____________________________ City_______________ State_____ Zip _______
Mailing address___________________________ City________________ State_____ Zip _______
Phone ___________________________________ Fax _________________________________
E-mail Address ___________________________ Web-Site ______________________________
Contact Name (not for publication) __________________________________________________
Days & Hours of Operation _______________________________________________________
Description of purpose/mission/services: ______________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Handicapped Accessible
yes
no
Interpretation Services
yes
no
Check all that apply:
Spanish
Korean
Sign Language
Other ___________________
Transportation Provided?
yes
no
Are you located on a city bus route?
yes
no
Age range served __________________________
Eligibility requirements ____________________________________________________________
Geographic area served, please identify with zip codes ____________________________________
Do you have free programs, services or admission days for our "What’s free for kids" list? _________
_____________________________________________________________________________
Can you recommend other organizations we should contact?
| Organization Name | Contact person | Phone |
| ________________________________ | ______________________________ | ___________________ |
| ________________________________ | ______________________________ | ___________________ |
| ________________________________ | ______________________________ | ___________________ |
| ________________________________ | ______________________________ | ___________________ |
| ________________________________ | ______________________________ | ___________________ |
The following is a list of possible subjects for the index. Please check the subject areas you want your organization listed under:
|
Adoption
|
Immunizations
|
Other Categories for Consideration
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please mail the survey back or fax to 867-7772.
Any questions? Contact Linda Blanton, R&D Director, at 867-9700 or lblanton@ccpfc.org.
Thank you for your participation!