Service Provider Registration From

Service Provider Registration From
The following form will be used to develop a comprehensive inventory of programs and services that we connect to our community.

We work to match resources to needs by age group, gender, family roles, and culture. Flyers and marketing materials to promote community participation are developed using two types of descriptions for each program or service:

Flyers and registration notices use a short two to three-sentence description. It should be intriguing and inviting to appeal to voluntary participants.

Your organization, and the program/service you would like to connect, may be listed on our website, added to our newsletter, and/or the registration process.
Your Organization
Website Address
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Facebook (social media accounts)
Program 1 Objective or Expected Outcomes:
Program Focus Area - Check All That Apply (Program 1)

EducationEmploymentFood SecurityFamily ServicesHealth ServicesHousingCrisis Intervention: Domestic Violence, Abuse, Human TraffickingImmigrationReentry & DiversionSupportive Services: (Multi-Disciplinary), MinistriesTechnical Support: Affordable Professional Services for Non-Profits and Programs
Level of Community Support - Check All That Apply (Program 1)

Train the TrainerDirect DeliveryWorkshopReferral Services
Participant Groups - Check All That Apply (Program 1)

AdultsParentsMomsDadsYouth 0 - 5Youth 5 - 9Youth 9 - 12Youth 13 - 15Youth 15 - 18Young Adults 19 - 24
Program Description:
For inclusion on flyers and websites, please send your logo to:
fbisby@jlbccommunityalliance.com
Thank you!
For submitting your program and for helping to plant the seeds of resilience!
Should be Empty: