ASSISTANCE LOCATION INFORMATION CHANGE REQUEST ASSISTANCE LOCATION INFORMATION CHANGE REQUEST This information will populate our community guide on where to find food, childcare and other resources while schools are engaged in COVID-19 related distance learning. Please note that this form should only be used to request changes to an existing resource location registration. Please only complete the your Organization Name and field(s) that pertains to your changes. There is no need to fill out any other fields on this form. Name of Organization as it appears on your current listing: * Tax ID / EIN: Type of Assistance providing: Food Meals Childcare Educational Activity Recreational Activity OtherOther Do you charge a fee for any of your services? If yes, what services do you charge for? Days of Operation: Sun Mon Tues Wed Thurs Fri Sat Hours of Operation: Number of Individuals Able to Serve Per Day: Age Groups Served Early Childhood / Pre-K K – 5th Grade 6th – 8th Grade High School Average total number of kids per group Ratio of kids to adults Action Required to Access Services: Walk In Call for Apointment Request Online OtherOther Please describe the services you are offering. If you have selected more than one action required to access your services, please indicate which action is required for each of your services. (Limit 250 characters) Will Your Organization Accept In-kind Donations for this purpose? If so, please select all that apply: Food Donations Clothing Donations OtherOther Are you willing to accept donations of food from resources such as the Food Bank? Yes No If yes, would your site like to receive free meals delivered to your site every day? Yes No Do you have refrigeration on site? Yes No Please select all the type of food donations you are willing to receive: Meal Components Prepared Meals Shelf-stable Meal Kits What meals would you like to receive? Breakfast Lunch Dinner Snacks Computer Accessibility for Distance Learning Yes No Internet Accessibility for Distance Learning Yes No Bilingual Supports Yes No Are masks required for youth? Yes No Are masks required for adults? Yes No Please Describe your Safety Plan Please describe your contact tracing plan (if someone has come in contact with COVID, how will families be notified?) Volunteer Information Are you willing to accept volunteers to assist in this effort? Yes No Public Service Contact Information Service Location Address: * Service Location Address: Service Location Address: Service Location Address: City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Contact Phone: Organization Website: Organization Social Media: Program Contact Information (Will not be included in public resource listing) Contact First Name: * Contact Last Name: * Contact Email Address: * Submit If you are human, leave this field blank.