Database Inclusion Request Form

Database Inclusion Request Form

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

Street Address

Street Address Line 2

CityState / Province

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

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Website
E-mail*
Agency Type*

For profitNon-profitGovernmentOther, please specify below
Other? Specify
Does you agency have an office located in Kenosha?*

YesNoOffice 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 CodePhone Number
Toll free or additional phone numbers

Area CodePhone Number
Fax number

Area CodePhone Number
Person for consumers to contact:
Full Name*

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

Accepts Medicaid (T19)Accepts MedicareAccepts Private insuranceNo cost for service
Eligibility requirements (Who do you serve?)*
Intake procedure (How do consumers obtain services)*
Service Area*

City of KenoshaCounty of KenoshaSoutheast WIStatewideNational
Accessibility*

Wheelchair accessibleFully accessibleCall for detailsN/A
License, Credentials, Accreditations
About your agency: Summary of what you provide and who you serve.*
Should be Empty:

Person for consumers to contact: