Agency Information Form

We are thrilled that you would like to work with Contact Helpline.  Please tell us about your agency or non-profit.  If you would prefer to download and hand write the application, just click HERE.

Instructions for completing this registration form: Tab or mouse to the fields below and enter all applicable information. Complete a PROGRAM INFORMATION section for each program/service your organization offers. When complete go to FILE > Send > Email. Email as an attachment to contacthelplinepa@gmail.com. If you have any questions about completing this registration form, please call the CONTACT Helpline business office @ 717 652-4987
Physical Address *
Physical Address
Is this address Confidential? *
Is your mailing address the same as your physical address? *
Mailing address if different than physical address
Mailing address if different than physical address
Phone *
Phone
Fax
Fax
TTY
TTY
Toll Free
Toll Free
Organization Information
Please tell us about yourself
Please tell us about your agency
Agency Director / Administrator Information
Director / Administrator Name *
Director / Administrator Name
Administrator Phone *
Administrator Phone
Adminstrative Contact Person
Please provide us with someone for us to contact with questions about this form and to request updates from. This information is not made available to the public.
Contact Name *
Contact Name
Contact Phone *
Contact Phone
Certification
I hereby certify that the above named agency meets one of the following criteria (Check all that apply): *
May we disseminate your information? *
In addition to providing information about your organization’s services over the telephone. CONTACT Helpline disseminates information in printed directories and an online database. Many social service professionals and others use this information to refer their clients to your organization and programs. Please feel free to call us at 717 652-4987 if you have concerns or questions.
Authorization
By placing your name below, you authorize Contact Helpline to evaluate this application.
Authorized Name *
Authorized Name
By printing your name, you hold that you are authorized to submit this application on behalf of your agency, non-profit or organization.
Today's Date
Today's Date