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Part 1: Agency Contact and Demographic Information
1.
Name of Agency
2.
Main Office Address
3.
Agency Phone Number
4.
City, State, Zip
5.
Name of Agency CEO
6.
CEO's Direct Phone Line
7.
CEO's Cell #
8.
CEO's Email Address
9.
If your agency has the following staff members, please list name and email address and best phone number to contact them .
Assistant/Associate Director
CFO
COO
Program Manager
Clinical Director
Director of Development
Communications/Marketing Professional
Human Resources Professional
Information Technology Professional
Volunteer Services Professional
Advocacy Liaison
Executive Administrative Assistant
10.
Name of Board President
11.
Name of Board President Elect
12.
Please indicate the approximate percentage of the following that are Jewish
0-10%
0-10%
11-20%
about 25%
26-40%
about 50%
51-70%
about 75%
100%
Clients
0-10%
0-10%
11-20%
about 25%
26-40%
about 50%
51-70%
about 75%
100%
Board of Directors
0-10%
0-10%
11-20%
about 25%
26-40%
about 50%
51-70%
about 75%
100%
Volunteers
0-10%
0-10%
11-20%
about 25%
26-40%
about 50%
51-70%
about 75%
100%
13.
Please list the number of clients your agency has served in each of the following demographic groups during the last fiscal year:
Adolescents
Ex-offenders
Infant/Toddlers
Jewish
Long Term Unemployed
Older Adult Workers (55+)
Older Adult Workers Not employed
Persons with Disabilities
Refugees/Immigrants
School Age Children
Veterans
Welfare Recipients
Young Adults (ages 18-22)
Other
Total Clients Served
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