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Program Information

Please complete all the information on this form so we can enter your program into our database.

Program Name 
Scholarship/Camp Name (if applicable) 
Address Line 

Address Line 

City, State and ZIP 
  
Local Phone 

Toll Free Phone 

Fax 
E-mail 

Website 

Application Form on Website 
No Yes - URL
Hours/Days of Service (If applicable) 
Who You Help (Be specific) 
Services You Provide/Benefits 
Geographic Area Serviced 
Eligibility Criteria 
How to Apply/Application Process & Requirements 
Is your organization non-profit?  Non-ProfitFor-Profit
Do you charge a fee?  YesNo If yes, how much?
Languages Spoken 

This following information is for our files only and will not appear on the website.

Please check one or more of these descriptions to help us categorize your program:
  This program or foundation is based on a specific disease or medical condition, assists patients with health-related expenses (including financial grants, insurance copays, the purchase of some health-related goods or other assistance with expenses).
  This program helps patients find and apply for Patient Assistance Programs and other types of assistance.
  This program is funded and/or administered by the state (all or in part).
  This is a Clinic that provides direct medical, dental or mental health services at little or no charge or on a predefined sliding scale.
Contact Person 
Contact's Phone 
Contact's Email 
Contact's Address
(if different from above) 
Other Comments