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KAN-I HELP Intake Form
Thank you for helping us expand our agency database. Our goal is to help citizens connect with the resources and services that they need to succeed. If you have any questions regarding the information intake process, please email
admin@kanihelp.org
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* Indicates required question
What is the name of your organization?
*
Your answer
Agency Type (Select all that apply)
*
Church Affiliated
Coalition/Other Group
County
Educational Institution
Federal
For-Profit
Municipal/City
Non-profit
State
Township
Required
Territory Your Organization Serves
Central Illinois
Iroquois County Only
Kankakee & Iroquois Counties
Kankakee County Only
National
Northeastern Illinois
State-wide (Illinois)
Clear selection
Languages Spoken (If any other than English)
Your answer
General Description of your Organization (1-2 sentences)
*
Your answer
Address (If multiple, please label location titles)
Your answer
Organization's Main Phone Number
Your answer
Organization's Secondary Phone Number (If number belongs to a separate addresses, please label accordingly)
Your answer
Toll-Free Phone (If applicable)
Your answer
Agency Email
Your answer
Website
Your answer
REQUIRED: What services does this organization offer? (Please label each service name and a brief 2-3 sentence description)
*
Your answer
Organization's Hours of Availability
Your answer
Contact Person: Name and Title (Please note if you would like for this contact to be listed OR unlisted - used for bi-annual email updates.)
*
Your answer
Contact Person's Phone Number and/or Email Address
*
Your answer
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