2018 Service Provider Form 2018 Service Provider Form Thank you for your interest in bringing your services to the people at Care Day 2018. Please fill out the form below to tell us about your contribution and provide details about your services, volunteer opportunities, and logistical needs. Please fill out all required (*) fields. Step 1 of 4 25% Provider Contact InfoAgency Name*Primary Agency Contact*For Care Day Coordinator's use. First Last Primary Contact Email* Primary Contact Phone*Agency Website Agency Address*For correspondence. Street Address Address Line 2 City State WAAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Briefly summarize what your organization does*Note: This question refers to your services during the year. Later we ask what you will be providing at Care Day.Contact info to provide Care Day GuestsNOTE: This information is for public use, to be given to Care Day service providers, volunteers and guests, if asked.Contact person for clients seeking your organization's services First Last Phone number for clients seeking your organization's services*Contact info for use by Emergency Responders, if applicable.This info will not be published to the general public, but may be used by local emergency services, such as police, fire and chaplains, when responding to people in need.If your organization has a person who can answer calls from Fire Fighters, Police, or City Chaplains, please list here.This would bypass any answering service or voice mail, connecting the Responder with immediate potential for service. (For example, a policeman would use this information if helping a homeless person in urgent need of your services.) First Last Organization's phone number for use by Emergency Responder on behalf of person in urgent needDaytime, if applicableOrganization's phone number for use by Emergency Responder on behalf of person in urgent needNights and weekends, if applicable Details About Resources ProvidedIn what section of Care Day should your agency be stationed?*Select the best category for your agency. We may need to situate you in a different area, depending on the space requirements, if your agency has multiple services. Family & Children Services Youth Services Housing Government Benefits Veterans Services Legal/Financial Services Employment Support/Training/Education Communications: Voicemail, email, phones Food banks/Community meals Haircuts/Personal Care Health Services & Information Medical Care & Screening Mental Health Dental Care Vision Care Books Portraits Other If you selected Other, please characterize your agency in 1-2 wordsPlease describe the specific things you will provide to clients at Care Day, such as: services, goods, information, sign-ups for your program.* Logistical DetailsWe will provide tables, chairs, and access to electricity. Please bring all other decorations for your tables (tablecloth, signage, "swag", etc.).Tables: how many 6' tables do you need?*Chairs: how many chairs will your Staff need?*Chairs: how many chairs will Guests need (if any) ?*Electricity: Do you need access to an electrical outlet?*YesNoInternet/WiFi: do you need access to WiFi?*We are dependent on the school district for this service, therefore we cannot guarantee its availability.YesNoPlease describe any special accommodations you may need day of the event. Volunteer and Communication NeedsDo you need volunteers to help at your table for the day of the event?*YesNo, we're fully staffedIf Yes, how many volunteers would you like?Volunteer Position Title* Volunteer Position Description*Do you need additional resources for communication?*Note - digital copies of all Care Day promotion materials are available on the Promotion page. We appreciate you printing your own copies where possible.No, we're good!Yes, printed copies of Promotion materials.Yes, custom needs.Describe any custom needs.Who else should be at Care Day 2018? Please suggest other resource providers that you think should participate (please include contact name and info).Almost done! Click the Submit button below.Thank you for taking the time to provide this information. We look forward to partnering together to bring vital services to our community at Care Day! If you have additional questions please contact Monette at firstname.lastname@example.org.