2017 Service Provider Participation Form

Project Homeless Connect is pleased to announce that we will again be holding  in Santa Cruz on July18th at the Santa Cruz Bible Church at 440 Frederick St, Santa Cruz, CA 95062 (Hours: 10:00am - 4:00pm, Setup starts at 8:00am on the 18th and is also open on July 17th from 4:00pm to 5:00pm). Providers are asked to bring previously issued navy blue PHC provider T-Shirts.  If you do not have one for you or your staff, we will try to one available for you.

Please complete this form to verify your participation in the July 18, 2017 Santa Cruz Connect event to be held at the Santa Cruz Bible Church.

The deadline for submitting this form is July 10 2017. Participation is not guaranteed and will be determined by the Santa Cruz Connect organizing committee. Direct service providers are encouraged to apply. Fees for services are prohibited and conditional service delivery is strongly discouraged. 

* 1. What is your agency/organization's name?

* 2. Is your organization a...

* 3. What service will you be providing on July 18, 2017?

* 4. How you would you categorize the services you will be providing?

* 5. How many people from your organization will be attending PHC to provide services?

* 6. What is the estimated dollar value of your contribution to PHC, including your staff time?

* 7. Does your service require anything that you cannot provide on your own? (e.g. WI-FI  electrical cords, etc)

* 8. On the day of the event, how many of the following items will you need? (Please Note: we cannot guarantee you receive these items)

  1 2 3 4 5
Chairs
Tables - 6 foot
Tables - 8 foot
Electrical Outlets

* 9. Who will be the primary contact for Santa Cruz Connect?

* 10. Email Address

* 11. Phone Number

* 12. Is your agency able to make a monetary donation to help with event costs?

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