Database Inclusion Request Form

Database Inclusion Request Form

If you’re interested in having your agency listed in the 211 Metro Chicago resource database, please fill out the following form. Before submitting, please search for your agency on 211metrochicago.org to see if your agency is already listed.

* Fields with asterisks are required to submit the form.

Submitter Information

Your Name*

Your Email Address*

Agency Information

Please start by telling us a bit about your agency.

Agency Name*

Agency Phone Number*

Phone

Agency Main Email*

Agency Website*

Agency Main Contact Person*

Site Information

Where is your main office located?

Site Address*

Site Hours of Operation*

Site Accessibility Information (check all that apply)

Wheelchair accessible

Blind/low vision accommodations

Deaf/hard of hearing accommodations

Program Information

What services does your agency offer that you’d like the community to know about? Please include any relevant information regarding eligibility, application process, and/or required documents. Please provide as much information as possible.

Program Description*

Is this agency currently receiving funding of any kind from United Way of Metro Chicago?*

Yes

Don't Know/Not Sure

Send me a copy of my responses

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