Agency or Program Service Information Form

Agency or Program Service Information Form

If you are not in our database and would like to be, or you are a provider in our database and have a new service to tell us about, please fill out and submit the form below. Or, print out this page, fill out the following information and mail it to the address below or attach it to an e-mail to archers@yourunitedway.org.

You must fill out a form for EACH individual Service.

To view the inclusion and exclusion criteria for this database, click here.

If you need to update information already in the database, please search for your agency and services, print out the information already in the database, make corrections on the print-out and mail it to Shelia Archer, United Way of Greater Richmond & Petersburg, P.O. Box 11807, Richmond, VA 23230 or submit it by e-mail to archers@yourunitedway.org.

All required fields must be filled in. When deleting an existing agency or program, please type 'Please delete program' in the program details section.

Agency or Program Name:  (required)

Physical Address:  (required)

City:  State:     Zip + 4: 

Mailing Address

Mailing Address: 

Mailing City:  State:   Zip + 4: 

Agency or/Program Also Known As: (Please list other names the public might know you as)
Telephone Numbers

Telephone 1:           Description:  (required)

Telephone 2:           Description: 

Telephone 3:           Description: 

Telephone 4:           Description: 

Fax: 

Electronic Information

Email Address:  (required)

Web Address: 

Program Details

Hours: 

Person in Charge:  (required)

Job Title:    

Eligibility: 

Fees: 

Intake: 

Languages: 

Area Served: 

Accessibility Information

Are you wheelchair accessible?  Yes     No 

Are you accessible by public transportation?  Yes    No 

Do you provide client transportation?  Yes   No 

Program Details

Tell us about your program:

 

Agency Type:

City Administered
County Administered
Faith-based
Federally Administered
For Profit
City Administered
Non-Profit, Inc.
Private, Non-Profit
State Administered

I acknowledge that the agency, program and service information I have entered will be included in the Virginia Statewide Information & Referral Database located on the internet at http://www.vaiandr.net/ and the United Way Services database at http://askunitedway.communityos.org/. I also understand that this information could be used to compile published directories and other information pieces.

Yes, I consent for this information to be made public.

 No, I do not want this information made public.

By affixing my signature electronically or in writing below, I certify that the information contained on this form is accurate and complete.

I also understand that the Virginia Human Services Information & Referral System and United Way Services reserves the right to exclude or remove any agency/program information from the Database. Inclusion into our database is a privilege, not a right.

Signed: 

Title:     

Date: