BCC Triage Network Intake Form

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Thank you for taking the time to fill out this form. Your participation in your community is what builds resilience. Let's build together!

Please answer each prompt with as much detail as you can. We will follow up with you to let you know the progress of uploading your organization onto our website and, if needed, to request more information.

Feel free to reach out to Serene at serenetownsell@gmail.com with any questions or concerns.

*The required fields are highly requested, but if the prompt is irrelevant to your organization please write "N/A".

Your Name

Your Email (for follow up) *

Organization Name *

Organization Acronym

Location *

Website *

Email *

Phone Number *

Mission *

List of Services

(i.e. grocery delivery, free diapers, childcare, housing assistance, tutoring, workshops, exercise programs)

Select the categor(ies) relevant to the organization *

Health (i.e. mental, physical, or spiritual health; recovery)

Education (i.e. tutoring, financial literacy, business workshops)

Career (i.e. skills training; resume critique and mock interviews)

Basics (i.e. food; clothes; diapers; hygiene)

Culture (i.e. community programming; cultural education)

Business (*this category is for local businesses)

Required

Do you wish to include a volunteer sign-up link to your BCC page? *

Yes

N/A

Do you wish to include a donate button to your BCC page? *

Yes

N/A

Social Media Handles

(please specify the platforms for each handle)

Other items you want shown on your organization's page

Other notes you want the BCC staff to know

Submit

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