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Jefferson County Resources Questionnaire
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Organization Name
*
What services are you offering? What distribution method is being used?
*
Contact Name
*
Contact Email Address
*
Organization Address
City
State
Zip Code
Contact Phone Number
*
Organization Website
Hours of Operation
What are the primary populations that your organizations serves?
*
All Populations
Communities of Color
Incarcerated or detained populations
Individuals experiencing homelessness
Individuals experiencing domestic violence
Individuals with disabilities
LGBTQ+
Low-income individuals/families
Populations experiencing hunger, food, or nutrition insecurity
Mountain community populations
Seniors
Undocumented populations
Uninsured populations
Children under 18
People whose native language is not English or with low English language proficiency
Do you provide any services in languages other than English? If so, which services and in what languages are they provided?
*
Are walk-ins accepted or do you need an appointment?
Walk-ins accepted but appointment is preferred
Walk-ins accepted
Appointment only
Is this service free or at cost? Please include cost in your answer.
*
What supplies or material resources does your organization need?
*
Self-stable Food
Fresh Food
Frozen Food
Cardboard boxes/bags for distribution
Safety Supplies (disinfectant, gloves, etc.)
Transportation
Volunteers
None
Any other information you would like us to know?
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