Barrier Busters Partner Resource Guide/Biennial Membership Update

Contact Information for Partner Resource Guide

Every two years, Barrier Busters’ member agencies renew their membership. Additionally, Barrier Busters maintains an online agency list, noting services provided and key staff contacts. Please fill out and return this survey by October 15, 2018.

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* 1. Formal Agency Name

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* 2. Agency Contact Person

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* 3. Agency Contact Phone Number

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* 4. Agency Contact Email

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* 5. If different from the formal agency name, how would you like your agency name to be listed in the Resource Guide?

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* 6. What Services does your agency provide (please check all that apply

Community Based Health Care

Financial Counseling

Helpline

Home Health Care

Hospital Services & Programs

Housing Services

Information & Referral Services

Insurance Counseling

Legal Services & Referrals

Mental Health or Substance Abuse

Nutrition Programs

Recreation

Rehabilitation Services

Residential & Community Independent Living

Resource Navigation

Senior Services

Support Groups

Transportation Services

Volunteering

Other (please specify)

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* 7. Agency Address to be printed in Resources Guide

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* 8. Agency Phone # to be listed in guide (please indicate type of phone (phone or fax)

Phone Number

Fax Number

Other

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* 9. Website to be listed in Resource Guide

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* 10. Agency Email to be listed in Resource Guide (if multiple emails are to be listed indicate what type of questions do you want directed to each Email).

Email 1

Email 2

Email 3

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* 11. How do you want the services provided by your agency listed in the Resource Guide?

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* 12. AGREEMENT LINK: What level of Barrier Busters membership does your agency want? NOTE: The documents provided in the links below are for review purposes only. You do not have to send signed copies of these documents to OCED.

Network Members (General) provides access to the listserv and professional development meetings. Please complete the form at this link

Network Members (Emergency Assistance Funds). Access to the listserv, professional development meeting and the Barrier Busters Emergency Unmet Needs Fund). Please complete the form at this link.

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* 13. DTE Online Resource for Agencies access (optional)

For those emergency assistance fund members who provide emergency utility screenings, a separate membership and training is available for DTE-ORA access, allowing DTE account lookup to designated staff. If interested, individual designated staff from your agency can fill the form at this link. Unlike the Network Member Agreements, the signed form should be scanned and emailed to l-bbstaff@listserver.washtenaw.org.

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* 14. Executive Director Electronic Signature. I have read and understand the Barrier Busters Membership agreement and authorize my agency to participate at the level checked above. Barrier Busters will email the Executive Director to verify authorization.

Executive DIrector Name

Executive Director Email

Executive DIrector Phone #

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* 15. Please indicate who you wish to have access as a Barrier Buster from your Agency.

Barrier Buster #1 Name, email & phone Number

Barrier Buster #2 Name, email & phone Number

Barrier Buster #3 Name, email & phone Number

Barrier Buster #4 Name, email & phone Number

Barrier Buster #5 Name, email & phone Number

Barrier Buster #6 Name, email & phone Number

Barrier Buster #7 Name, email & phone Number

Barrier Buster #8 Name, email & phone Number

Barrier Buster #9 Name, email & phone Number

Barrier Buster #10 Name, email & phone Number

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* 16. Do you need to be trained on any of the following?

Barrier Busters General Training - REQUIRED FOR ALL NEW MEMBERS - This is excellent training for a refresher in Barrier Busters overall services. You can take this training as often as needed.

MEAP Training - for Utilities assistance

DTE ORA training for Utilities Assistance

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* 1. Formal Agency Name

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* 2. Agency Contact Person

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* 3. Agency Contact Phone Number

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* 4. Agency Contact Email

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* 5. If different from the formal agency name, how would you like your agency name to be listed in the Resource Guide?

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* 6. What Services does your agency provide (please check all that apply

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* 7. Agency Address to be printed in Resources Guide

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* 8. Agency Phone # to be listed in guide (please indicate type of phone (phone or fax)

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* 9. Website to be listed in Resource Guide

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* 10. Agency Email to be listed in Resource Guide (if multiple emails are to be listed indicate what type of questions do you want directed to each Email).

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* 11. How do you want the services provided by your agency listed in the Resource Guide?

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* 12. AGREEMENT LINK: What level of Barrier Busters membership does your agency want? NOTE: The documents provided in the links below are for review purposes only. You do not have to send signed copies of these documents to OCED.

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* 13. DTE Online Resource for Agencies access (optional)

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* 14. Executive Director Electronic Signature. I have read and understand the Barrier Busters Membership agreement and authorize my agency to participate at the level checked above. Barrier Busters will email the Executive Director to verify authorization.

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* 15. Please indicate who you wish to have access as a Barrier Buster from your Agency.

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* 16. Do you need to be trained on any of the following?

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* 17. Anything else we should know?