HomeMy WebLinkAboutnew-program-update-formNEW PROGRAM FORM/UPDATEPROGRAM: ____________________________________________________________Other Name: _____________________________________________________________Contact Person: __________________________________________________________
Address: ______________________________________________________________________
City: _______________________________________ZIP Code: _______________________
Please give mailing address, if different:
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Phone: ( ) _____________________Office Hours: ___________________________
TTY: ( ) ____________________________________________________________
Fax: ( ) _____________________Program Hours: _________________________
email: __________________________________________________________________
web address: ___________________________________________________________________
ELIGIBILITY: Please indicate any eligibility criteria (age, geographic, type of disability,
ambulatory/non-ambulatory, etc.): _______________________________________________________
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PAYMENT: Please indicate any fees and third party payment (i.e. vendorization by Regional
Center, Rehabilitation, Medi-Cal, insurance, etc.): _____________________________________
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DESCRIPTION: Please give a program description. Use additional information if necessary.
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APPLICATION: Please indicate the application procedure, i.e. by telephone, by mail, in person, etc.:
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ACCESSIBILITY: Are all facilities wheelchair accessible? Please indicate any restrictions:
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Client/Staff Ratio (if applicable): __________________________________________________
PUBLIC TRANSPORTATION: Please indicate closest public transportation:
Closest bus line: _______________________________________________________________
Closest BART station: ___________________________________________________________
FOREIGN LANGUAGES/SIGN LANGUAGES: Please indicate if services are offered in any
foreign languages/sign. Which language(s)? __________________________________________
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SPECIAL TARGET POPULATION(S): Are your programs specific to one particular target
population? Please indicate: _______________________________________________________
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