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* 1. Please indicate your role in our Community: 

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* 2. In which county do you live or is your agency located?

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* 3. Please tell us the top three needs of our community.

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* 4. Please list any service for low-income or otherwise vulnerable populations that need to be provided, improved, and/or expanded in our community. 

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* 5. Basic Education (GED, Adult Education) Services are:

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* 6. Basic Education (GED, Adult Education) Services are:

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* 7. English as a Second Language Courses are:

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* 8. English as a Second Language Courses are:

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* 9. Safe, Affordable Child Care is:

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* 10. Safe, Affordable Child Care is:

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* 11. Preschool Education is:

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* 12. Preschool Education is:

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* 13. Help Enrolling in College or Technical School is:

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* 14.  Help Enrolling in College or Technical School is:

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* 15. Affordable Medical Care is:

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* 16. Affordable Medical Care is:

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* 17. Affordable Dental Care is:

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* 18. Affordable Dental Care is:

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* 19. Help Getting Enough Food is:

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* 20. Help Getting Enough Food is:

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* 21. Mental Health Services / Family Counseling is:

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* 22. Mental Health Services / Family Counseling is:

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* 23. Drug / Alcohol Treatment and Counseling is:

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* 24. Drug / Alcohol Treatment and  Counseling is:

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* 25. Teen Pregnancy Resources are:

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* 26. Teen Pregnancy Resources are:

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* 27. Services for those who have been Sexually Assaulted are:

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* 28. Services for those who have been Sexually Assaulted are:

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* 29. Affordable Housing is:

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* 30. Affordable Housing is:

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* 31. Mortgage/Rental Assistance is:

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* 32. Mortgage / Rental Assistance is:

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* 33. Help Buying Gas (for Transportation) is:

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* 34. Help Buying Gas (For Transportation) is:

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* 35. Help with Utility Bills is:

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* 36. Help with Utility Bills is:

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* 37. Help Finding a Job is:

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* 38. Help Finding a Job is:

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* 39. Job Training is:

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* 40. Job Training is:

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* 41. Help Finding a Job that Pays a Living Wage is:

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* 42. Help Finding a Job that Pays a Living Wage is:

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* 43. Help Repairing Credit is:

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* 44. Help Repairing Credit is:

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* 45. Budgeting Skills Training is:

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* 46. Budgeting Skills Training is:

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* 47. Public Transportation is:

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* 48. Public Transportation is:

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* 49. Low-Cost Legal Help is:

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* 50. Low-Cost Legal Help is:

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* 51. Parenting Support is:

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* 52. Parenting Support is:

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* 53. Services for the Elderly are:

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* 54. Services for the Elderly are:

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* 55. Please leave any additional comments in the box below.

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