Health Improvement Programs (211) -2nd round

This form collects program information to be posted under Health Improvement Programs on the 211 Adirondack Region website (211adk.org). Please submit one form for each program your agency hosts.

Question Title

1. Service (Program Name):

Question Title

2. Program Category (select all that apply):

Nutrition

Physical Activity

Obesity Prevention

Mental Health

Parenting

Chronic Disease Management

Diabetes Management

Arthritis Management

Weight Management

Question Title

3. Description of Service (Program):

Question Title

4. Location (County):

Clinton County

Essex County

Franklin County

Question Title

5. Geographical Area (Please enter the name of the Town(s) where the program site is located):

Question Title

6. Eligibility (Please list any client requirements or restrictions; e.g., age limits, residency, income level, referral needed, etc):

Question Title

7. Intake Requirements (Please provide information related to your program registration procedure, etc):

Question Title

8. Types of Fees:

None/No charge

Associated Fee (please describe/specify amount):

Question Title

9. Specific Hours (Please provide information about dates/times when program is held):

Question Title

10. Physical Site Address (location where program is held):

Main Site Name *

Address *

City/Town *

ZIP Code

Question Title

11. Facility/ADA (Please provide any additional information about the Physical Site where the program is held. If none, select "Do not display this field"):

Do not display this field

Facility Description:

Question Title

12. Affiliated Agency (host agency or agencies):

Question Title

13. Contact Info:

Website Address: *

Contact Person Name:

Email Address: *

Main Phone Number: *

Thank you for your submission. If you have another program to enter please click "Done" before you open a new form.