Project Homeless Connect 3: East County Service Provider Form

We need your help!
Please fill out one form for each program providing services within your organization.
Download the form (PDF, 1p.)

Agency Name:
Program:
Agency Mailing Address:
City & Zip:
Contact Person (responsible for disseminating event information/instructions to program):

Work Phone:
Cell Phone:
e-mail address:
Please list all persons who will be providing services from your program: First Name: Last Name: e-mail:
Please indicate if you are:
County program
Non-profit organization
Private organization
We expect that you will be able to provide services for the duration of the event (9 a.m. through 3 p.m.). Set up is scheduled for 7 a.m.
Which services would you like to provide (please check all that apply):
Medical	Mental Health	Dental
Substance Abuse	Vision/Glasses	Youth
Employment	Family	HIV Services & Testing
Legal	Veterans	Animal Services
Shelter Services & Other Housing Information		DMV
Personal Care (e.g. hair care, manicure/pedicure, other) - licensed practitioners only - Please indicate:
Special Needs and Senior Services		Wheelchair and bicycle repair
Benefits Assistance (e.g. GA, TANF, SSA - SSI/SSDI, payee services): Please indicate:
Please indicate your requirements:	Number of Tables	Number of Chairs
Any other special requirements you will require (we will do our best to provide you with what you need but we cannot guarantee that we can do so):

Please be prepared to provide your own signs for your tables.Thank you.

Please fax printable form to: 925-313-6761.
Thank you for your generosity!

Content provided by the Homeless Programs of Contra Costa Public Health Division. For more information, call 925-313-6124.