New Partner Interest Form

New Partner Interest Form

Thank you for your interest in being a Partner Agency with CRC. Please complete the following form so that we may best determine your organization's eligibility. After reviewing your submission, we will follow up with our decision regarding if we would like to move forward with your organization in our application process.
1. Agency Name*
2. Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Our agency is (please select any/all that apply):*

A federally tax-exempt 501(c)3 or 501(c)4 non-profit public charity in current and good standing with the TN Secretary of State OfficeA church, synagogue, temple, or other faith communityA government agencyOther
4. What counties does your agency serve? Please check all counties where your agency provides services.*

CheathamDavidsonRobertsonRutherfordSumnerWilliamsonWilsonOther
5. Do you ask clients for donations, charge a fee, or require attendance at a service or gathering to receive services?*

YesNoOther
6. Tell us about your agency and your interest in partnering with the Community Resource Center.*
Please provide a brief description of your organization's program(s) to help us better understand how you serve your community and how you intend to use hygiene products obtained from the CRC.
7. Does your agency provide products and/or services at more than one location/site?*

YesNo
7a. Please list all locations where your agency provides products and services.*
Please include site name and full address for each location.
8. Select the type(s) of service(s) your agency provides. Please check all that apply.*

Food PantryOutreach to the Unhoused/Homeless CommunityShelter (Homelessness, Domestic Abuse)Residential (Substance Abuse, Mental Health, Senior Adults, Veterans, Re-entry, Youth, etc.)Youth - DaycareYouth - Afterschool Program, Summer ProgramDomestic Violence Support ServicesImmigrant/Refugee Support ServicesIncarceration Support ServicesFamily/Caregiver Support ServicesSenior Support ServicesVeterans Support ServicesDisaster Relief Support ServicesRehabilitation Support ServicesFoster Care/CPS Support ServicesOther
For the question below, please refer to these Agency type definitions:
- An "Open" agency is an agency where the general public has access to your resources/services.
- A "Program Only" agency is an agency whose resources/services are provided exclusively to clients that are engaged in the agency’s programming and do not offer resources/services to the general public.
9. What is your Agency type?*

OpenProgram Only
10. Does your agency currently provide personal hygiene or cleaning products to your clients/service population?*

Yes, free of chargeYes, but we charge a fee or other financial costNo, it is requested but we don't have capacity to offerNo, not applicable to our work
11. What is the total number of unique individuals your agency typically serves annually?*
If your agency does not track this data, please provide your best educated estimate.
12. What is the average number of individuals your agency typically serves in a month?*
If your agency does not track this data, please provide your best educated estimate.
Agency's Main Contact - Name*
First and Last Name
Agency's Main Contact - Role*
What is your title/role within the agency?
Agency's Main Contact - Email*
example@example.com
Agency's Main Contact - Phone Number*
Signature of Authorized Representative from Your Agency*

Clear
Agency's Main Contact - Name

First NameLast Name
4. Agency EIN
6. Agency's Website and Social Media Channel(s)
Please provide the website URL as well as the handles for any/all of your agency's social media channels.
7. What year was your agency founded?
8. What is your agency's mission and vision?
9. Are the resources/services you provide accessible to the community-at-large?

YesNo, our services are limited to our specific client group(s)Other
14a. What are the most requested or distributed items?
14b. What method(s) does your agency currently use to stock your shelves with hygiene and/or cleaning products? Select all that apply.

In kind product donations from donorsRescue or salvaged products from businessesGrants specific to hygiene/person care productsInternal budget allocationOther
18. What percentage of your clients/participants qualify as low-income?
19. Please describe what indicator(s) you use to identify clients/participants as low-income (free/reduced lunch, at or below Federal Poverty Line, SNAP/WIC eligibility, etc.)
20. If we move forward with a partnership with your agency, are you willing to inform and amplify our work through agreed upon data reporting requirements and storytelling?

YesNoMaybe
1. Are you a registered 501(c)3 or 501(c) 4 organization in current and good standing with the TN Secretary of State Office?

YesNo
2. Does your agency serve in one or more of these counties: Cheatham, Davidson, Robertson, Rutherford, Sumner, Williamson, Wilson?

YesNo
3a. Please upload your agency's 501c(3)/501c(4) Designation Letter.

Cancelof
18. Do 51% or more of the clients your agency serves fall at or below the Federal Poverty Line?

YesNo
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