Idealistics SafetyNet - Pomona - Service Provider Intake

Service Provider Intake Form

This service provider intake form collects data on programs available to residents of the City of Pomona. The information you provide will be consolidated into the City's SafetyNet system. SafetyNet organizes community data and helps those in need easily locate available community programs. The City of Pomona SafetyNet system will be publicly accessible starting September 13, 2007. Thank you for taking the time to fill out this quick form!

If you are a service provider, it is very important that you fill out a separate form for each program that your organization offers. Please contact Idealistics with any changes to the information you have provided.

* If you have any questions about the SafetyNet system, or your submission to this database, please call Idealistics at (909) 632-1346.

Program Information

Agency Name *required (e.g. City of Pomona)
Program Name *required (e.g. Weed and Seed Program)
Phone Number *required	( ) -
Street Address
City
State
Zip
Website
Program Description *required
Program Hours *required (e.g. Monday - Friday 9AM - 5PM)
Is there a fee? *required (If yes, include pricing information in the Eligibility question below)	No feeThere is a fee
Eligibility requirements for this program *required (Does this program only work with certain demographic groups? Are there Income limits per family size? Is there a sliding scale fee? Etc.)
Keywords (Words that help somone locate this program. For example, a shelter may have keywords of "homeless" "housing" "transitional", etc.)
Check all languages this services is available in	English Spanish Vietnamese Tagalog Chinese
If offered in another language, please specify

Contact Information

Contact Person (Name of best contact for this program)	First Last
Title
Email
Phone Number	( ) -
Fax Number	( ) -

About You

Person completing this form *required	First Last
Agency
Title
Email
Phone *required	( ) -

Evaluation Questions

The following information will be used exclusively by the City of Pomona Youth and Family Master Plan and will not be shared with any other public or private agencies.

Total number of hours this program is available per week.
Please describe the results of the most recent evaluation of this program.
What is the targeted number of participants to be served in the current calendar year?
How many unduplicated participants were served by this program in the last calendar year?
How long has this program been available in Pomona?

Thank You!