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together in texas
For Couples For Providers
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Search for Marriage Education Services
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Registration for Twogether Service Provider

1. Name of person completing this form.

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2. Who would we contact to update the information on this organization in the future.

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* Required Field

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4. ADDRESS

What is the street address of your organization (main office)?

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Is this address confidential?  
Is this address a residence?  

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Is this address confidential?  

5. ORGANIZATION FUNDING

What are the sources of funding for the organization? Please choose all that apply.


6. Service Goals



TYPE OF SERVICE*

1. What type of marriage education do you provide?

2. How many hours is your program?*



**Other

3. What Type of schedule do you provide for your program?




NAME OF CURRICULUM*



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1. LOCATION SERVED

Please list the city/zip codes where this service is/are being offered.

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2. If you have one specific location where all services are offered, please complete this section.

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Address :
County :
 

Is this site accessible by public transportation (within 1/4 mile of a stop)?

    

Is this site accessible by wheelchair?

    

3. HOURS and DAYS of OPERATION

On what days and during what hours do you intend to offer services? (Check all that apply)

1. TARGET POPULATION


Do you offer services in Spanish?

     


Do you offer services in any other language(not English or Spanish)?

     


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2. FEES

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TypeNote
  
  


Complete ONLY if a program and you offer on-going registration

1. Person to contact to register:

Authorization to Publish Information

Organization Name : 

In addition to relaying information about your organization’s services over the telephone, 2-1-1 Texas and Twogether in Texas will disseminate information in printed directories and in an online database, which is available at www.211texas.org. Many social service professionals and volunteers at churches, nonprofit organizations, schools, and government agencies use this information to refer their clients to organizations and programs. Please feel free to call us if you have concerns related to this form.

This signed release form will be retained on file as an ongoing authorization that 2-1-1 Texas and Twogether in Texas may provide information to the public regarding the services of the above-named agency.

, I hereby authorize Twogether in Texas and 2-1-1 Texas Information and Referral Network to utilize my organization’s information for inclusion in any print or online publications of community resources. Information that is noted as confidential on the agency/program forms will not be given to callers, nor will it be published in other formats.

, Twogether in Texasand 2-1-1 Texas Information and Referral Network does not have authorization to print my organization’s information in any print or online publication of community resources. The information will continue to be provided to individuals who call the 2-1-1 helpline for assistance.



Name :  

Title :  

Date    3/15/2010

 

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