2-1-1 PROGRAM INCLUSION FORM

United Way of Forsyth County
301 N. Main Street, Ste. 1700
Winston-Salem, NC 27101
Phone (336) 723-9378
Fax (336) 724-1045
Email: kathleen.wiener@uwforsyth.org

Agency/Program Contact Information: This program form should be completed by all agencies who wish to be included in the North Carolina 2-1-1 database. Please complete a separate form for each program.

Fields marked with an * are required



PROGRAM PHYSICAL ADDRESS



PROGRAM MAILING ADDRESS - IF DIFFERENT

 

ADMINISTRATIVE AND INCLUSION INFORMATION



PHONE AND OTHER CONTACT INFORMATION

Please enter all pertinent phone numbers, including specialized hotlines or intake lines that may be helpful to callers.



PROGRAM INFORMATION

Please provide as much detailed information as possible so that only appropriate referrals are directed to your program.