KARL Database Inclusion Request Form

Database Inclusion Request Form

Kenosha County Aging and Disability Resource Center
Please fill out this form to submit your agency and its programs to be considered for inclusion in the Kenosha County Aging and Disability Resource Center community resource database. For more information, view the Agency Information page within the database.
Agency Name*
List other names your agency is known by, such as acronyms
Agency Type*

For ProfitNonprofitGovernmentOther
Please specify the type of agency.
Agency Email*
Please enter a valid email, ex. test@gmail.com
Agency Phone Number*
Please enter a valid phone number (123) 456-7890
Additional Phone Numbers
Please enter any toll free or additional numbers
Agency Fax Number
Please enter a valid fax number
Agency Website
Agency Service Area*

City of KenoshaKenosha CountyRacine CountyWalworth CountySoutheast WIStatewideNational
Number of years your agency has held a Kenosha/Kenosha County address.
Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Does your agency have a separate mailing address?*

YesNo
Agency Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Agency Business/Service Hours*
Agency Office Accessibility*

Wheelchair accessibleFully accessibleCall for detailsN/A
Please describe your agency. What services do you provide? Who do you serve?*
Please describe any eligibility requirements for who you serve.*
Please describe your intake procedure, how consumers obtain services.*
Does your agency charge for its services?*

YesNo
Fees for Provided Services
Payment Methods Accepted

Accepts Medicaid (T19)Accepts MedicareAccepts Private Insurance
Agency Licenses, Credentials, and/or Accreditations
Contact First and Last Name

First nameLast name
Contact Title*
Languages Spoken and/or Translation Services Available*

EnglishSpanishChineseTaglogGermanFrenchOther
Please specify other languages spoken and/or translation services available
Should be Empty: