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211 Site/Location
Please fill out the following questions. Please write down each physical location where your services are offered. If you have any issues completing the form, please contact
kflores@unitedwaysc.org
. Thank you for completing this form.
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* Indicates required question
Your Name and Email
*
Your answer
Name of your agency:
*
Your answer
Name of location
*
Your answer
Address of location
Your answer
Description of Location
Your answer
Disabilities Access
*
Fully accessible to individuals using mobility aids
Potential limitations to access – call for details
Service area is not accessible by wheelchair
Designated, accessible parking spaces
What bus service a client should take
Your answer
Mailing address
Your answer
*OPTIONAL* Name, address (physical and mailing), if ADA accessible (Disabilities Access) of Additional Location
Your answer
*OPTIONAL*Name, address (physical and mailing), if ADA accessible (Disabilities Access) of Additional Location
Your answer
*OPTIONAL* Name, address (physical and mailing), if ADA accessible (Disabilities Access) of Additional Location
Your answer
*OPTIONAL* Name, address (physical and mailing), if ADA accessible (Disabilities Access) of Additional Location
Your answer
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