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211 Program
Please submit one Program Application per program. If you have an issue on the form or are unable to submit the form, please contact
kflores@unitedwaysc.org
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* Indicates required question
Email
*
Your email
Name of Agency (ANSWER BELOW)
*
Your answer
Name of Program (ANSWER BELOW)
*
Your answer
Description of Program (ANSWER BELOW)
*
Your answer
Program Eligibility (ANSWER BELOW)
*
Your answer
Languages Offered (ANSWER BELOW)
*
Your answer
Payment options
*
No fee
Fees vary
Set program fee
Sliding scale
Accepts Medi-Cal
Accepts Medicare
Accepts most insurance
Scholarships available
Donation requested
Membership fee
Call for fee information
Unknownn
Required
Application Process (ANSWER BELOW)
*
Call to apply
Call for intake
Call for an appointment
Visit during program hours
Call or visit
Required
Documents Required
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Your answer
Does your agency provide services during Public Safety Power Shutoffs (PSPS) or disasters?
We anticipate ongoing services will be available during a PSPS event
We plan to provide additional services during PSPS events or during disasters (please note below)
We do not plan to provide additional services during PSPS or disasters
Not sure
Please list any additional services your agency may provide during a PSPS event or disaster.
Your answer
Hours of Operation: Include Days and Hours
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Your answer
Program Main Phone Number
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Your answer
Program Main Email
*
Your answer
Website
*
Your answer
Location of Program and Address (include address if program is not the main agency location)
*
Your answer
Program Main Contact Name and Email (ANSWER BELOW)
*
Your answer
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