Agency Application

Thank you for your interest in having your agency listed in the 211 Ventura database. If your agency is not in the 211 Ventura database, please use the form below to submit your application.

Does your organization provide services that are appropriate for inclusion in the 211 database, based on the 211 Ventura County Inclusion/Exclusion Policy? YesNo

Have you been in operation for at least six months?YesNo

Your Name*

Your Email Address*

Agency Information

Agency Name*

Agency Description* (describe your agency in one or two sentences)
e.g. Nonprofit organization focused on supporting low-income families in Ventura County.

Agency Type*
—Please choose an option—Not-for-profit (incorporated)Not-for-profit (not incorporated)Government - FederalGovernment - StateGovernment - CountyGovernment - CityFaith-basedMembershipSpecial DistrictPrivate PracticeFor-profit/Commercial
Agency Website

Agency General Email (for public use)

Physical Address*

Is this location wheelchair accessible?*
YesNo
Is this location confidential?
YesNo

Mailing Address*

Administration Office Hours*

Agency General Phone Number*

TDD/TTY Number (if any)

Agency Primary Contact Information

Agency Primary Contact Name*

Agency Primary Contact Title*

Agency Primary Contact Email*

Agency Primary Contact Phone Number*

Agency Senior Executive Information

Senior Contact Name

Senior Contact Title

Senior Contact Email

Senior Contact Phone Number

Program Information

Program Name*

Program Description* (maximum of 100 words)
(e.g. Offers parenting skill classes to parents struggling with managing misbehavior of their children at home or school.)

Program Residency Requirement*
—Please choose an option—No residency requirementMust be a citizen of the United StatesMust be a California residentMust be a Ventura County residentMust be a resident of a specific city-explain through program Eligibility belowMust be a resident of a specific zip code-explain through Eligibility below

Program Eligibility* (e.g. Must be parents with children under 18 years old.)

Language Offered*
EnglishSpanishOtherInterpreter Services Available

Other languages (if choose "Other" in the previous question)

Program Fees*
No feeFees vary based on incomeFees vary based on servicesSliding scale fee based on incomeSet program feeAccepts Medi-CalAccepts MedicareAccepts most insuranceMembership fee

Fee information (explain fee range for sliding scale, fees vary, set program fee, membership fee, etc.)

Program Intake Procedure*
—Please choose an option—Visit during program hoursCall or visitCall for an appointmentCall for intakeCall to applyReferral required-provide additional notes belowOther-provide additional notes below
Additional notes on Intake Procedure (e.g. Clients must be referred by a school counselor.)

Document Required at Intake* (e.g. ID, SSC, Proof of Income, etc.)

Program Website

Program Hours*

Program Phone Number 1* (required) and phone description (e.g. 805-111-1111 Main Number)

Program Phone Number 2 (if any) and phone description (e.g. 805-111-2222 Oxnard Office)

Program Phone Number 3 (if any) and phone description

TDD/TTY Number (if any)

Program Physical Address 1* (required) where the service is offered

Is this location wheelchair accessible?* YesNo
Is this location confidential? YesNo

Program Physical Address 2 (if any) where the service is offered

Is this location wheelchair accessible? YesNo
Is this location confidential? YesNo

Program Physical Address 3 (if any) where the service is offered

Is this location wheelchair accessible? YesNo
Is this location confidential? YesNo

Program Mailing Address*

Additional Information