Database Inclusion Request Form

Database Inclusion Request Form

Kenosha County Aging and Disability Resource Center
Agency Name *
Address *

Street Address

Street Address Line 2

City State / Province

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

Yes No
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Website
E-mail *
Agency Type *

For profit Non-profit Government Other, please specify below
Other? Specify
Does you agency have an office located in Kenosha? *

Yes No Office in Racine County or Walworth County
Number of years your agency has held a Kenosha County address:
List other names your agency is known by (names the agency may be recognized as, such as acronyms)
Phone number *

Area Code Phone Number
Toll free or additional phone numbers

Area Code Phone Number
Fax number

Area Code Phone Number
Person for consumers to contact:
Full Name *

First Name Last Name
Title *
Languages Spoken and/or translation services available *
Business/Service Hours *
Fees *
Payment accepted

Accepts Medicaid (T19) Accepts Medicare Accepts Private insurance No cost for service
Eligibility requirements (Who do you serve?) *
Intake procedure (How do consumers obtain services) *
Service Area *

City of Kenosha County of Kenosha Southeast WI Statewide National
Accessibility *

Wheelchair accessible Fully accessible Call for details N/A
License, Credentials, Accreditations
About your agency: Summary of what you provide and who you serve. *
Should be Empty:

Person for consumers to contact: