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Organization Contact Information and Registration for Youth Services Summit (6/17/19)
Information to share with other Youth Service Providers and funders in areas impacted by the Camp Fire.
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Email
*
Your email
Contact Information
Name
*
Your answer
Position/Title
Your answer
Organization
Your answer
Organization Short Name/Acronym
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
Will you be attending the Youth Services Summit on 6/17/19
*
Yes
No
Maybe
Organization Webpage
Your answer
Organization Information
Please tell us a little about your organization.
Organization Type
*
Business
Government
Health
Individual
Non-Profit Organization or Club
Religious Affiliation
School or College
Other:
Organization Focus
Agriculture
Cultural, Historical, or Museum
Education
Environmental
Funding
Health or Behavioral Services
Natural Resources
Recreation
Scientific Research
Sports or Activity
Youth Activities
Other:
Clear selection
Budget (Closest Estimate Pre-Campfire, FY 2018-2019)
$0 or none.
Less than $100,000
$101,000 to $250,000
$250,001 to $500,000
$500,001 to $1,000,000
$1,000,001 to $2,000,000
$2,000,000 to $5,000,000
Greater than $5,000,000
Clear selection
Number of Employees (Pre-fire in terms of Full-Time Equivalent (FTE)
None
1-5
6-10
11-20
21-50
Greater than 50
Clear selection
What is your Organization's ability to provide services in comparison to your pre-Camp Fire status?
Poor - Severe Impacts
1
2
3
4
5
Excellent - Minimal impacts
Clear selection
Briefly Describe Organization and Mission
Your answer
Summit Questions
Your answers will help us provide an overview of organizations and help shape the agenda. Please complete as best as you can -- we understand the uncertainty!
What services did your Organization provide before the Camp Fire?
Your answer
What is your Organization's current status? (Where are you? Facilities damaged? Providing services?)
Your answer
What does your Organization need the most? (check all that apply)
Customers/Clients
Facilities
Funding
Transportation
Partners
Staff
Outreach
Other:
What is the greatest need for area youth?
Your answer
What is the greatest opportunity for increased collaboration with area partners?
Your answer
Are you interested in participating in future events to share your services with the public and explore needs with local youth and providers?
Yes
No
Maybe
Other:
Clear selection
What do you hope to gain the most from participation in the Summit?
Your answer
Any additional comments?
Your answer
A copy of your responses will be emailed to the address you provided.
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