Your Full Name

Your Work Email

Felton Institute Program Name

Program Acronym

Program Webpage URL

Program Contact Email

Program Contact Phone Number

Fax

Office Opening Hours Office Opening Hours Select as many as apply. Monday - Friday, 9:00 AM - 5:00 PM By Appointment 24/7, 365 Other, please describe ...

Other Hours of Operation

Service Areas Service Areas Select as many as apply. Aging Services Case Management Clinical Services Crisis Support Early Care & Education Early Intervention Family Support Services Health & Wellness Homelessness Support Justice Services Mental Health Services Supportive Housing Technical Assistance Training Workforce Development

Ages Served Ages Served Select as many as apply. All Ages Infants/Toddlers (birth - 2) Preschool (ages 2 - 5) Children (ages 6 - 12) Teens (ages 13 - 17) TAY (ages 14 - 24) Adults (ages 18+) Older Adults (ages 55+)

Does the Program Provide Volunteer Opportunities? Does the Program Provide Volunteer Opportunities? Selecting “Yes” means we’ll follow up with you to gather info about your volunteer needs and help promote the opportunity. Yes, we are seeking volunteers

Program Overview Blurb

Program Mission/Goals

List of Services

Who We Serve

Do Participants Pay or Receive Compensation?

What year was your program started/founded?

Client Eligibility and Program Enrollment Client Eligibility and Program Enrollment Select as many as apply. Eligibility Requirements — Clients must meet specific criteria (e.g., age, income, residency) to qualify. Enrollment Requirements — Clients must complete an application or intake process before joining. Referral Required — Enrollment requires a referral from a licensed professional, social worker, or government agency. Open Enrollment — Open to the general public; no referral required. Clients can enroll directly. Walk-Ins Welcome — Site is open to the public on a drop-in basis; no appointment needed. Screening/Assessment — Clients are evaluated during intake, for example, to determine needs, eligibility, or appropriate service level. Insurance Accepted — This program accepts health insurance coverage.

Eligibility List

Enrollment Process

Referral Process

Intake Process

Accepted Insurance Options

Name of Funder (Organization, Grant, or Agency Funding Your Program)

Funder Contact Name

Funder Contact Email

Funder Contact Phone Number

Is the program contractually required to include a funding statement on its webpage and marketing materials? Is the program contractually required to include a funding statement on its webpage and marketing materials?Yes, a funding statement is contractually required.Not required, but we include a funding statement voluntarily.No, we do not include a funding statement and are not required to.

Funding Statement

Funder Logo (If you have it) attach an approved to use funder logoFile InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png. Max. file size: 50 MB

County Location by CountyAlameda CountyContra Costa CountyMarin CountySan Benito CountySan Francisco CountySan Mateo CountySanta Clara CountySanta Cruz CountySolano CountySonoma County

Street

City

State

Postal Code

Parking Information

Service Area (Geographical Reach)

Featured Program Image (Optional) Upload featured photo(s) to represent your program or program site location.File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png. Max. file size: 50 MB

Scope Of Work (Optional) Upload your program’s Scope of Work (SOW) and/or documentation listing contact info for multiple funders.File InputChoose FilesNo Files ChosenAccepted file types: csv, pdf, doc, docx, xlsx, xlsm, xlsb, numbers. Max. file size: 24 MB

Certification Certification I hereby certify that, to the best of my knowledge, the provided information is true and accurate.