<div class="fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_1 1_1 fusion-flex-column" style="--awb-bg-size:cover;--awb-width-large:100%;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:10px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;"> Complete all applicable information. If a field does not apply to your organization, please specify N/A. Complete a separate form for each program your agency offers. Please enable JavaScript in your browser to complete this form. PROGRAM INFORMATION Program Name: * Agency Name: * Purpose of Program: * Services Offered (Be as specific as possible. Callers are referred to your program based on this information.) * Payment Options (Select all that apply.): * Cash/Checks Credit Cards Insurance Medicare Medicaid No Fees/Charges Languages (Other than English): Intake Process: * Eligibility Requirements: * Documentation Required: * Handicap Accessible? * Select one. Yes No Geography Served: * Funding (e.g. government, private donations, grants): * Upload brochures or other documentation to aid in the understanding of services provided. (File type must be .pdf or .jpg, and smaller than 2MB.) <path d="M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z"> Click or drag files to this area to upload. You can upload up to 3 files. AGENCY INFORMATION. Only complete if the information below is different than the agency information provided. Days and Hours of Operation: Name of Person in Charge: First Last Title of Person in Charge: Physical Address: Address Line 1 Address Line 2 City --- Select state --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Organization Phone: Organization Alternate Phone: Organization 24 Hr Phone Number or 8YY Number: Organization Fax Number: Organization Email: Organization Website URL: ACKNOWLEDGEMENT Name of Person Completing This Form: * First Last Email of Person Completing This Form: * Submit

211: Get Listed

Are you a nonprofit in Kansas that would like to list your program(s) in the 211 database? It’s easy!

Complete the agency and program forms below. Remember, an agency is the organization that hosts the program and programs are specific services, such as an employment workshop for adults. Please complete all required fields. If it does not apply to your agency or program, list N/A.

Questions? Contact Michele Grimm, United Way 211 Coordinator, at (316) 267‑1321, ext. 4301, or mgrimm@unitedwayplains.org.

211 Agency Formkgoertzen2024-05-15T18:00:40-05:00

211 Agency Form

Complete all applicable information. If a field does not apply to your organization, please specify N/A.

ORGANIZATIONAL INFORMATION

Agency Name: *

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different than physical address):

Address Line 1

Address Line 2

City

State

Zip Code

Organization Phone: *

Organization Alternate Phone:

Organization 24 Hr Phone Number or 8YY Number:

Organization Fax Number:

Organization Email: *

Organization Website URL:

PERSON IN CHARGE AT ORGANIZATION

Name of Person in Charge: *

First

Last

Title of Person in Charge: *

Phone Number for Person in Charge: *

Email for Person in Charge: *

CONTACT PERSON (Communicates with 211 for listing updates)

Name of Contact Person: *

First

Last

Title of Contact Person: *

Phone Number for Contact Person: *

Email for Contact Person: *

ORGANIZATION DETAILS

Days and Hours of Operation: *

Agency Type/Legal Status: *

Employer Identification Number (EIN XX-XXXXXXX):

Upload IRS Nonprofit Determination Letter (File type must be .pdf or .jpg, and smaller than 2MB.):

Click or drag a file to this area to upload.

Organization Mission/Purpose: *

Upload brochures or other documentation to aid in the understanding of services provided. (File type must be .pdf or .jpg, and smaller than 2MB.)

Click or drag files to this area to upload. You can upload up to 3 files.

Handicap Accessible? *

Geography Served: *

Licenses or Accreditations:

ACKNOWLEDGEMENT

Name of Person Completing This Form: *

First

Last

Email of Person Completing This Form: *

211 Program Formkgoertzen2024-05-15T18:00:35-05:00

211 Program Form

Complete all applicable information. If a field does not apply to your organization, please specify N/A. Complete a separate form for each program your agency offers.

PROGRAM INFORMATION

Program Name: *

Agency Name: *

Purpose of Program: *

Services Offered (Be as specific as possible. Callers are referred to your program based on this information.) *

Languages (Other than English):

Intake Process: *

Eligibility Requirements: *

Documentation Required: *

Handicap Accessible? *

Geography Served: *

Funding (e.g. government, private donations, grants): *

Upload brochures or other documentation to aid in the understanding of services provided. (File type must be .pdf or .jpg, and smaller than 2MB.)

Click or drag files to this area to upload. You can upload up to 3 files.

AGENCY INFORMATION. Only complete if the information below is different than the agency information provided.

Days and Hours of Operation:

Name of Person in Charge:

First

Last

Title of Person in Charge:

Physical Address:

Address Line 1

Address Line 2

City

State

Zip Code

Organization Phone:

Organization Alternate Phone:

Organization 24 Hr Phone Number or 8YY Number:

Organization Fax Number:

Organization Email:

Organization Website URL:

ACKNOWLEDGEMENT

Name of Person Completing This Form: *

First

Last

Email of Person Completing This Form: *

211 Anger Management and Parenting Resources Formkgoertzen2024-05-16T09:53:12-05:00

211 Anger Management and Parenting Resources Form

Parenting classes and anger management classes will be published in their respective resource guides. Resource guides are available to agencies and consumers in print and available for download at unitedwayplains.org/211. This information is updated regularly. Please contact 211 or check the website for the most current guides.

Information is provided as a community service and does not necessarily constitute endorsement or approval by United Way of the Plains.

List only one class per form. Submit form as many times as needed.

PROGRAM INFORMATION

Course Name: *

Agency Name: *

Type of course. *

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Number of Sessions: *

Time: *

Start Date: *

Cost: *

Name of Contact Person: *

First

Last

Contact Phone: *

Contact Email: *

Other Information: *

Handicap Accessible? *

Geography Served: *

Upload brochures or other documentation to aid in the understanding of services provided. (File type must be .pdf or .jpg, and smaller than 2MB.)

Click or drag files to this area to upload. You can upload up to 3 files.

ACKNOWLEDGEMENT

Name of Person Completing This Form: *

First

Last

Email for Person Completing This Form: *