Today's Date:

-- mm/dd/yy

Membership Status:

New Member
Existing Member

A.1. Name of Organization:

A.2. Director's Name & Title:

First Name
Last Name
Title

A.3. What year was your organization founded or incorporated?

2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Before 1900

A.4. What is your organization type?

Not for Profit For Profit Faith Based City Agency State Agency County Agency Federal Agency Individual (not incorporated) Other

If other, please list here:

A.5. Briefly summarize your organization and its mission (250 character limit):

A.6. How does the client access services?

Walk-in                    Call-in                    Appointment Only           Referral by a Provider   
Hotline Service (24 hour)  

A.7. Population Served

Age:

Under 18      18 - 24       25 - 50       51 and Above

Gender:

Male    Female  Other   

Offenders:

Violent Offense  Sex Offense      Drug Offense     Arson Offense  
Theft Offense    

Level of Offense:

Felony       Misdemeanor  

B.1. Physical Address :

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

B.2. Mailing Address (If different from above) :

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

Monday Office Hours:

Tuesday Office Hours:

Wednesday Office Hours:

Thursday Office Hours:

Friday Office Hours:

Saturday Office Hours:

Sunday Office Hours:

B.4. Primary Contact Person Name:

First Name
Last Name

B.5. Primary Contact Person Phone Number:

Work Phone

B.6. Primary Contact Person Fax Number:

FAX

B.7. Primary Contact Person Email Address:

E-mail

B.8. Web Site Address:

URL

B.9. Hotline Number:

Hotline

B.10. May we include a link from our web page to yours?

Yes No

B.11. Does your organization have additional branch or satellite offices?

Yes No

If yes, please list satellite offices here:

B.12. Does your organization have brochures? (If yes, please provide your most recent brochures via email as pdf files. Please mail to the Office of Reentry, if digital copy is not available.)

Yes No

B.13. May we include your organization in our "Reentry Resource Book"?

Yes No

B.14. May we include your organization in our online database?

Yes No

B.15. Does your organization have presenters/trainers available on areas of (if yes, please submit documentation):

employment                  education/vocational        housing                     substance recovery        
mental health, life skills  cognitive skills            other                       

If other presentation/training topics chosen, list here:

B.16. Is the building/office accessible to people with disabilities?

Yes No

B.17. Service Area (Check all that apply):

Akron-East         Akron-North        Akron-South        Akron-West       
Barberton          Bath               Clinton            Copley           
Cuyahoga Falls     Fairlawn           Green              Hudson           
Lakemore           Macedonia          Mogadore           Munroe Falls     
Northfield         Norton, Peninsula  Richfield          Stow             
Tallmadge          Twinsburg          

B.18. Is your agency located on a bus route?

Yes No

If yes, which bus route(s)?

B.19. Approximately how many employees do you have?

1 - 19 20 - 49 50 - 99 100 - 499 500+

B.20. Please check/list all accreditations:

B.21. Please list all licensures:

B.22. Please list all affiliations and partner agencies: