United Ways serving San Bernardino County
PROGRAM/SERVICE REGISTRATION FORM
E-mail to: dflores@ieuw.org | Fax to: (909) 980-2957 | Call (909) 980-2857 ext. 220 for mailing address
1. PROGRAM NAME: Please provide any names the program may also be known as in the community (former
names, acronyms, etc).
2. PROGRAM/SERVICES ADDRESS: (Where program/services are delivered.)
offered at main agency
3. ADDITIONAL PHONE NUMBERS: List and identify phone numbers used for these program/services.
Phone Number:
Details:
Phone Number:
Details:
Fax Number:
Details:
Additional Numbers and Details:
4. PROGRAM DESCRIPTION: Please describe the specific services provided and the population it serves.
This information may or may not be published in directories, so please be as comprehensive as possible,
while brief. Also, be wary of jargon, abbreviations and acronyms. (Note: United Way 2-1-1 reserves the right
to edit as necessary for space consideration and consistency.)
Describe services:
Do you offer any special services (ex. for holidays, special circumstances or ?
Do you accept collect calls?
Yes
Yes
No
No
Do you offer internships?
Yes
No
If yes, describe education level, supervisor credentials, etc.):
5. HOURS: Please identify hours that relate ONLY to these program/services:
Business Hours (Specify days of the week and times):
Intake Hours (Specify days of the week and times):
6. AREAS SERVED: Please indicate the communities that are served. Describe service area limitations:
None (serve people who live anywhere in San Bernardino County)
Limited to the following area, check all that you serve:
Central Valley
Bloomington
Colton
Devore
Fontana
Grand
Terrace
Rialto
San
Bernardino
East County
Calimesa
East Highland
Highland
Loma Linda
Mentone
Redlands
Yucaipa
High Desert
Mid Desert
Mountains
West End
Apple Valley
Barstow
Hesperia
Lucerne
Valley
Phelan
Victorville
Wrightwood
Big River
Joshua Tree
Morongo
Needles
Twenty-Nine
Palms
Yucca Valley
Big Bear
Blue Jay
Crestline
Lake
Arrowhead
Running Springs
Alta Loma
Chino
Etiwanda
Montclair
Ontario
Rancho
Cucamonga
Upland
Other
Specify area using zip codes or write your own area designations:
2-1-1 San Bernardino County | www.211sb.com | Page 1 of 3
United Ways serving San Bernardino County
7. POPULATION: Will services be rendered to people outside the target population?
Yes
Does your program target particular groups?
Yes
No If yes, check all that apply:
Age Groups
Infants/Toddlers (0-3)
Children (4-12)
Youth/Adolescents (13-17)
Senior Citizens (60+)
Employment
Employed
Unemployed
Ethnicity
African Americans
Caucasians
Hispanics/Latinos
Native Americans
Asians/Pacific Islanders
Middle Easterners
Household
Families
Separated Families
Parents
Adoptive Children
Foster Children
Income
Poverty Level
Low-Income
Moderate Income
Marital Status
Single
Married
Separated Persons
Divorced Persons
Widowed Persons
Military
Active Duty Military
Retired Military
Veterans
Sex
Females
Males
Sexual Orientation
Gay Men
Lesbian
Bisexual
Transsexual
Disabilities
Developmental
Eating Disorders
Hearing Impairments
Homebound
8. ELIGIBILITY REQUIREMENTS: Does your program restrict services?
If yes, please check all that apply:
Income Status:
Ethnic Origin:
Gender: Males
Age Range:
Age Range:
Female
Other:
Please indicate additional criteria required for
participation in or access to program/services.
2-1-1 San Bernardino County | www.211sb.com | Page 2 of 3
No
Learning Disabled
Mental/Emotional Disturbance
Multiple Disabilities
Physical Disabilities
Visual Impairments
Focus
Abused/Battered Persons
At Risk Youth
Bereaved Individuals
Caregivers
Citizenship
Crime Victims
Homeless People
Migrants
Offenders
School Dropouts (Youth)
Students
Substance Abusers
Recovering Drug Abusers
Other
Yes
No
Family Composition
Families with Children
Singles
Couples
Agency or professional referrals required.
Describe:
United Ways serving San Bernardino County
Does your program provide:
Primary Services (services available to anyone in the community)
Secondary Services (only serve clients already involved in your programs;
ex. childcare for people taking English as a Second Language classes)
9. OTHER REQUIREMENTS: Is the participant required to complete any obligations to your organization to
receive the service?
Yes
No If yes, explain:
10. FEES: Are there any fees for this program?
Yes
No If yes, explain:
Ability to pay/Sliding scale
Donation requested for service
Fixed fees
Other:
If there is any other fee information that is pertinent to clients, please list here:
Does this program provide scholarships or a subsidy arrangement for low-income clients?
Yes
No If yes, please explain:
11. INSURANCE: Check all that apply:
Medicare
Medi-Cal with Medicare Only
None
Military Insurance
Private Insurance
Medi-Cal
Other
12. LANGUAGES: Please list the languages (other than English) that are routinely available and spoken by staff
and/or volunteers providing services.
13. INTAKE PROCEDURE: Please check all procedures that this program uses for intake:
Phone
Walk-in
Appointment required
Referral required by:
Other:
Is there a waiting period for service?
Yes
No
If yes, explain how long:
14. CHANGES: Do you expect any agency changes within your program in the next 6 months?
Yes
No If yes, please describe:
15. VOLUNTEERS: Are volunteer opportunities available for this program?
Yes
No
Please have Inland Empire United Way contact me about creating volunteer opportunities in my agency.
16. DISASTER: Does the program currently offer any services related to disaster preparedness or response, or
would it in the event of a disaster?
Yes
No
If yes, please explain:
17. AGENCY CONTACT: (Person to contact for verification of agency listing.)
Name:
Title:
Phone:
Person completing this form:
E-mail:
Date:
Print out, sign and fax to (909) 980-2957, ATTN: 2-1-1 Resource Specialist
Note: By signing this form, you give consent for your information to be posted on the 2-1-1 website and in
the annual resource book.
2-1-1 San Bernardino County | www.211sb.com | Page 3 of 3