New Program Application

If you have already signed up as a provider, the next step is to add a new program!

*If you have already filled out an application for a program, but want to make a change, please email us at 211scc@unitedwaysc.org

Provider Name

What is the name of your program?

Describe the Program

Program Eligibility

Languages Offered

Application Process

Documents Required

Does your agency provide services during Public Safety Power Shutoffs (PSPS) or disasters?

We anticipate ongoing services will be available during a PSPS event

We plan to provide additional services during PSPS events or during disasters (please note below)

We do not plan to provide additional services during PSPS or disasters

Not sure

OtherOther

Please list any additional services your agency may provide during a PSPS event or disaster.

Hours of Operation: Include Days and Hours

Program Main Phone Number

Program Main Email

Website

www.

Location of Program and Address (include address if program is not the main agency location)

City

State/Province

Zip/Postal

Country

Program Main Contact Name and Email

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