HomeMy WebLinkAbout211 Palm Beach - Treasure CoastPolm eemh,Treosvre Cowl*
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AFFILIATE AGREEMENT
To ensure continuity of care and support to clients, 211 Palm Beach/Treasure Coast enters into the
following agreement with:
City of Sebastian
(Print or type your agency name here.)
211 Palm Beach/Treasure Coast agrees:
CICS0301
To refer callers, who meet the eligibility requirement(s) of the Affiliate, to the Affiliate without
regard to race, color, creed, disability, national origin, age, sex, sexual orientation or economic
status for assessmentlon-going services.
To be available as a resource to the Affiliate's clients 24 hours a day for telephone counseling and
information and referral to community resources.
To be available to the affiliate's staff for information about and referrals to community resources.
The Affiliate agrees:
1. To receive clients, who meet the eligibility requirement(s), without regard to race, color, creed,
disability, national origin, age, sex, sexual orientation or economic status who are referred by 211
Palm Beach/Treasure Coast.
2. To advise clients of the 24-hour availability of 211 Palm Beach/Treasure Coast services.
3. To advise staff of the availability of 211 Palm Beach/Treasure Coast as a resource.
4. To inform 211 Palm Beach/Treasure Coast when changes arise within the Affiliate-
5. That information provided is true and accurate to the best of their knowledge and that this
information may be included in published materials and in local or statewide databases.
6. To provide 211 Palm Beach/Treasure Coast a yearly formal update when requested beginning at
the start of each calendar year for accuracy, deletion and new content. Agencies can update
formally during the year using the online update process proactively on the website.
This letter of agreement will remain in force until terminated by either party contingent upon thirty (30)
days written notice.
211 PALM BEACH/TREASURE COAST:
4KK
Susan K. Buza. Executive Director
January 2. 2015
Date Signed
AFFI LI ATE:
Date Signed
11/26/2014
211 Palm Beach Treasure Coast
Page 4 of 4
Information from 211 Community Resource Database
211 Database Update
211 Palm Beach/Treasure Coast
PO Box 3588
Lantana, FL 33465
To: Judi Hechtman
Phone: (561) 383-2162
Email: judi.hechtman@211 pbtc.org
Fax: (561) 383-2172
Date: J11 D IIS Pages:
From: I
Agency Name: l� / 1F� n ��rA'g64 4tv
Contact Name: �ntr/n tl� �I��T Ft 4J
Phone Number: 779 - CC) w 33- 0'1 r
I have reviewed the details of our agen site(s)/service(s), and:
The information is correct
We are enclosing corrections
City of Sebastian
Agency #:
CICS0301
1225 Main Street
Last Formal Update:
5/20/2014
Sebastian, FL 32958
Record Owned By:
CICS
Date Entered:
10117/1995
Mailing Address:
1225 MAIN ST
Affliliate Agreement Date:
5/20/2014
Sebastian. FL 32958
Phone Number
(772) 589-5330
Agency County:
Also Known As:
Agency Type:
Person In Charge:
In Charge Title:
Email:
Website:
Hours of Operation
EXT Dept/Contact
INDIAN RIVER
Municipal Government
Joe Griffin
City Manager
jgriffin@cityofsebastian.org
www.cityofsebastian.org
Monday -Friday / 8 am-4:30 pm
Agency Fax
(772) 589-5570
Year Incorporated:
IRS Status:
Agency FEIN:
License/Accred.:
Annual Budget: $0.00
Source of Funds:
Notes/Description: Municipal government.
Site (Location)
Site Name: City of Sebastian Site ID: CICS0301AC
1225 Main Street Last Formal Update: 5/20/2014
Sebastian, FL 32958
11/26/2014 Page 1 of 4
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
Palm ueacWrreasure Coost
�'AV•2 na
Get Connected. GetAnsty m
AFFILIATE AGREEMENT
To ensure continuity of care and support to clients, 211 Palm Beach/Treasure Coast enters into the
following agreement with:
City of Sebastian
(Print or type your agency name here.)
211 Palm Beach/freasure Coast agrees:
CICS0301
1. To refer callers, who meet the eligibility requirement(s) of the Affiliate, to the Affiliate without
regard to race, color, creed, disability, national origin, age, sex, sexual orientation or economic
status for assessmentlon-going services.
2. To be available as a resource to the Affiliate's clients 24 hours a day for telephone counseling and
information and referral to community resources.
3. To be available to the affiliate's staff for information about and referrals to community resources.
The Affiliate agrees:
1. To receive clients, who meet the eligibility requirement(s), without regard to race, color, creed,
disability, national origin, age, sex, sexual orientation or economic status who are referred by 211
Palm Beach/Treasure Coast.
2. To advise clients of the 24-hour availability of 211 Palm BeachlTreasure Coast services.
3. To advise staff of the availability of 211 Palm Beach/Treasure Coast as a resource.
4. To inform 211 Palm Beach/Treasure Coast when changes arise within the Affiliate.
5. That information provided is true and accurate to the best of their knowledge and that this
information may be included in published materials and in local or statewide databases.
6. To provide 211 Palm Beach/Treasure Coast a yearly formal update when requested beginning at
the start of each calendar yearfor accuracy, deletion and new content. Agencies can update
formally during the year using the online update process proactively on the website.
This letter of agreement will remain in force until terminated by either party contingent upon thirty (30)
days written notice.
211 PALM BEACH/TREASURE COAST:
J /
Susan K. Buza, Executive Director
January 3, 2014
Date Signed
AFFILIATE:
Date Signed
2/17/2014
211 Palm Beach Treasure Coast
Page 4 of 4
Information from 211 Community Resource Database
Fax Cover Sheet
211 Palm Beach/Treasure Coast
PO Box 3588
Lantana, FL 33465
To: Judi Hechtman
Phone: (561) 383-2162
Email:judi.hechtman@21Ipbtc.org
Fax: (561) 383-2172
Date: 15-IV- /T Pages:
From:
Agency Name: �
Contact Name: U v U
Phone Number:
I have reviewed the details of our agency/slte(s)/service(s), and:
The Information is correct / lam`— �5
We are enclosing corrections �V/ cya-�•-^-
6
City of Sebastian
1225 Main Street
Sebastian, FL 32958
Mailing Address:
1225 MAIN ST
Sebastian, FL 32958
Phone Number
(772)589-5330
Agency County:
Also Known As:
Agency Type:
Person In Charge:
In Charge Title:
Email:
Website:
Hours of Operation
Notes/Description:
Agency#:
CICS0301
Last Formal Update:
5/6/2013
Record Owned By:
CICS
Date Entered:
10/17/1995
Affllliate Agreement Date:
6/8/2012
EXT Dept/Contact Agency Fax
(772) 589-5570
INDIAN RIVER Year Incorporated:
IRS Status:
Municipal Govemment Agency FEIN:
CAAeph License/Accred.:
City Manager Annual Budget: $0.00
arrtt.10?ourceofFunds:
www.cityofsebastian.org 0
Monday -Friday / 8 am-4:30 pm
Municipal government.
Site Name: City of Sebastian
1225 Main Street
Sebastian, FL 32958
Site ID: CICS0301AC
Last Formal Update: 5/6/2013
2/17/2014
211 Palm Beach Treasure Coast
Pagel of 4
Information from 211 Community Resource Database
Site Malliny Address:
CITY COMPLEX 1225 MAIN ST
Sebastian, FL 32958
Phone Number EXT Dept/Contact Site Fax
(772) 388-8200 (772) 581-0149
Please Complete this section and include/send a coov of vour AHCA License. if this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker and Companion Service, Nurse Registry
Facility/Provider Type:
License Number: License Expiration Date:
Also Known g dd
Person In Charge: er ��-'iP
In Charge Title: City Manager Site Accessibility:
Site Email: `"buus Arcess:
"
Site Website: www.cityofsebastian.org
Site Hours: Monday -Friday / 8 am-4:30 pm
Notes/Description: Municipal government.
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — --
Site Service ID: CICS002389
Program Name:
Taxonomy Code Site Service
TD-6600.4500 Local Officials Offices
Target Terms:
In Charge:
Service Phone: ��rh
Ext:
Site Service Email: aaaiaaer@cityofsebastian.org
Site Service Website:
www.cityofsebastian.org
Site Service Fees:
No fees charged.
Site Service Hours:
Monday -Friday / 8 am-4:30 pm
Service Area:
City of Sebastian
Service Intake Process: Contact by phone.
Service Eligibility:
No restrictions.
Documents Required:
Language(s):
English.
Notes/Description:
Municipal government.
2/1712014
Use Reference Terms
City Government Offices
City Officials Offices
County Government Offices
County Officials Offices
Municipal Government Offices
Town Government Offices
Title:
Phone 2: Fax:
211 Palm Beach Treasure Coast
Page 2 of 4
Information from 211 Community Resource Database
Site Name: Police Department (Sebastian) Site ID: CICS0301AB
1201 Main Street Last Formal Update: 5/6/2013
Sebastian, FL 32958
Site Mailing Address:
1201 MAIN ST
Sebastian, FL 32958
Phone Number EXT Dept/Contact Site Fax
(772) 589-5233 Non -emergency calls
Please Complete this section and Include/send a coov of vour AHCA License, if this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker and Companion Service, Nurse Registry
Facility/Provider Type:
License Number: License Expiration Date:
Also Known As:
Person In Charge: Cheif J. Morris
In Charge Title:
Police Chief Site Accessibility:
Site Email:
smarcinik@cityofsebastian.org Site Bus Access:
Site Website:
www.sebastianpd.org/
Site Hours:
Every day / 24 hours
Notes/Description:
— — — — —
Local law enforcement agency.
— — —
— — — — — — — — — — — — — — — — — — — — — — — — — — — --
Site Service ID: CICS002386
Program Name:
Taxonomy Code Site Service
FL-6500 Municipal Police
Target Terms:
In Charge:
Service Phone: (772)
589-5233 Ext:
Site Service Email: smarcinik@cityofsebastian.org
Site Service Website:
www.sebastianpd.org/
Site Service Fees:
No fees charged.
Site Service Hours:
Every day / 24 hours
Service Area:
Sebastian
Service Intake Process: Contact by phone.
Service Eligibility:
No restrictions.
Documents Required:
Language(s):
English.
Notes/Description:
Local law enforcement agency.
Phone 2:
Use Reference Terms
City Police
Local Police
Police Departments
Township Police
Village Police
Eviction Notice
Title:
Fax:
2/1712014
211 Palm Beach Treasure Coast
Page 3 of 4
Information from 211 Community Resource Database