All Stars Partner Information Form

All Stars Partner Information Form

Thank you for your interest in joining the DOEA All Stars Partnership Program! As one of Florida’s smallest state agencies, community partnerships are a large component to fulfilling the needs of seniors across Florida.

The Department of Elder Affairs looks forward to adding you to our ever-growing partner database as we continue to fulfill our mission to promote the well-being, safety, and independence of Florida's seniors, their families, and caregivers.

Date*

How did you hear about the All Stars Partnership Program?*

Select

Other*

Please let us know how you heard about our All Stars Partnership Program.

Partner Name*

Partner Address*

MUST include Street, City, State, Zip Code

Partner Website*

Partner Point of Contact Name*

Partner Point of Contact Email*

Partner Point of Contact Phone Number*

Phone

Services for Seniors*

Does your organization provide services for seniors in the state of Florida?

Select

What counties does your organization serve?*

If you serve all 67 counties, please select the ALL option.

Select

What services does your organization provide?*

Examples of services: food, transportation, respite, application assistance, employment services, etc.

Service Criteria*

Are there specific criteria to receive services from your organization?

Select

Did you answer YES to the above question?*

If you answered YES to the above question, please note specific information to qualify for services (Medicaid, Medicare, Income, Age, etc.). If you answered NO, please put n/a.

Is your organization in need of volunteers?*

Select

Volunteer Need*

If you answered YES to needing volunteers, please specify the type of volunteer opportunities available, i.e., sorting food, administrative, etc. Please be as specific as possible.

Additional Partner Information*

Please note any other details you would like us to know about your organization.

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