The Bag Project New Organization Enrollment Form Step 1 of 2 50% Thank you for your interest in the Bag Project! Please complete the form below. Organization Name:* Name of Contact Requesting Bags:* First Last Title of Contact:* Phone:*Email:* Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Alternative Contact Name: First Last Alternative Contact Title: Alternative Contact Phone:Alternative Contact Email: Alternative Contact Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What population(s) do you serve?* Youth at Risk of.... Violence, etc. Foster or Kinship Resource Families Families Experiencing Homelessness Other If other, please describe:* What county/counties do you serve?* How many children do you serve per month?* What are the ages of the children you serve?* Newborn Infant/Toddler (1 month - 3 years) 4-5 Years Old 6-8 Years Old 9-11 Years Old 12-14 Years Old 15-18 Years Old The following information is only for record keeping purposes, your answers do not help or hurt your chances of being provided our service.What is the ethnic/racial makeup of the clients you serve? Actual figures are preferable, but if they are not available, please give us your best estimate. When added together they must total 100%.Black/African American* White* Hispanic/Latino* American Indian* Asian* Pacific Islander* Multi-Racial* Do the clients you serve have an income requirement to work with you?* Yes No Do you verify the income of your clients?* Yes No What percent of your population served is below the federal poverty level (FPL - Less than $31,200)? What percent of your population served is at FPL or below (FPL - Less than $31,200)? What percent of your population served is above 1-2 times the FPL (FPL - Less than $31,200)? What percent of your population served is greater than 2 times the FPL (FPL - Less than $31,200)? What percent of your population served has no poverty status on record? What percent of your population served identifies as LGBTQIA+? How would you classify your organization?*Organization ClassificationCareer Technical TrainingChild Abuse Resource CenterChurch Outreach MinistryCommunity Development CorporationCommunity Health Program or ClinicCommunity Outreach ServicesCorrectional Facilities / Jail / Prison / Legal SystemCrisis / Disaster ServicesDevelopmental Disabilities ProgramDomestic Violence ShelterEarly Childhood Education / Childcare / Early Childhood ServicesEducation ProgramFamily Resource CenterFood Bank / PantryFoster ProgramGovernment Agency / AffiliateHead Start / Early Head StartHome VisitsHomeless Resource CenterHospital Resource CenterHospital Infant / Child Pantry / ClosetLibraryMilitary Bases / Veteran ServicesPolice StationPregnancy Resource CenterPreschoolRefugee Resource CenterSchool - Elementary SchoolSchool - Middle SchoolSchool - High SchoolSenior CenterTribal / Native-Based OrganizationTreatment ClinicWomen, Infants, and ChildrenOther (Please list)Please classify your organization:*How did you hear about The Bag Project?* I have received bags previously embrella Newsletter embrella Website Colleague Social Media Another Organization (Please list) Which organization?* Are you receiving embrella's email newsletter?* Yes No What additional information would you like to see in the newsletter?Would you like to be added to our mailing list?* Yes No Preferred Email Address* TERMS AND CONDITIONS* I agree to the TERMS AND CONDITIONSTERMS AND CONDITIONS I agree to, and understand the importance of completing The Bag Project's Annual Feedback Survey. I agree to, and understand the importance of completing The Bag Project's Evaluation Survey. I understand that in order to continue participating with future Bag Programs, I must participate in the aforementioned feedback surveys. By signing below and engaging in The Bag Project, I have read, understood, and agree to execute these TERMS AND CONDITIONS on the date entered below. Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY If you have any questions, please contact Laura Nicholls, Communications Outreach and Volunteer Administrator, lnicholls@embrella.org. or call 609-631-5525. CAPTCHA Δ
