KidsPriorityOne
Connecting Children & Families to Resources

Hampton Roads regional database and website resource of human service agencies working with children, youth and families

FOR ASSISTANCE COMPLETING THIS DATABASE FORM, PLEASE CALL 757-244-5373

Your Information

Your information is required and allows you to save the form at any time and edit it later.

Name:

Email:

Phone:

(Note: To save and have this form emailed for completion later, click here.)

1. Agency / Organization Name

Name:
Alternate Names and Acronyms:	Please list all other names your organization may be known as, including acronyms, abbreviations, etc; for example, HNNCSB, H-NNCSB, Hampton-Newport News CSB.

2. Agency/Organization Type

Check all that apply: (Please check at least one.)

3. Coalition/Network Affiliations

Check all that your organization is a member of:

4. Agency/Organization Description.

Summarize the agency's/organization's services, programs, and who you serve. Space is limited to 350 characters. Specific program information is collected later.
	(characters remaining)
Example: The Helping Agency is a non-profit organization helping people with basic needs of emergency shelter, stable housing, food, clothing, and linkage to ongoing services. Eligibility is based on low-income and proof of residency.

4a. Who do you serve? Check all that apply

Check all that apply:

Infants/Toddlers
Children (ages 3-5)
Children (ages 6-10)
Youth (ages 11-18)

Parents / Adults
Women only
Women/children
Men only

4b. Name any populations the organization does not serve.

(For example, youth or adults w/ histories of sexual perpetration.)

4c. What year was the organization established?

5. Agency Main Address, Phone, Fax, Website & E-Mail Address

Address:
Address 2:
Address 3:
City:		State:	Zip:
Main Phone:		Main Fax:
Website:
General E-Mail:	(to be shown on KPO website)
Does the agency operate from multiple locations?: Yes No

6. Agency Director Information

Director Name:
Director Email:
May we publish this e-mail address? Yes No

8. Alternate Contact Person (For KPO internal use only.)

(i.e. Admin. Assist., Business/Office Manager, Deputy Director.)

Alternate Name:
Alternate Title:
Alternate E-Mail:	(will not appear on KPO website)

9. Localities Served

We serve all of Hampton Roads. (No limitations by locality.)

10. Agency Licenses & Accreditations

(List all pertaining to AGENCY. Program licenses captured later)

11. Agency or Program Awards Received

12. General Fee Information

(Specify general information. )