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2. Name of Agency*
4. Adult Day Services Site Location Address*
6. Office Address (if different from ADS site)
8. Phone Number*
10. Website
12. Name of Point of Contact*
14. Phone Number of Point of Contact
16. Age Range of People Served*
18. Program Days & Hours*
20. Services You Provide*

    1. Adult Day Services
    2. Community Integration
    3. Career Planning
    4. Group Employment Supports

    1. Individual Employment Supports
    2. Transportation
    3. Vocational Habilitation
    4. Other
22. If you selected "Other" above, please explain.
24. Description of Your Agency and its Services*

    Please explain your philosophy of service, what makes your agency unique, and share any other details about the services you offer. Please limit this to three paragraphs.

26. Questions?

    Should you have any questions about this form or encounter issues with completing it, please contact Amy Banks at 937-732-3706 or Janice Saddler Rice at 937-776-0866.

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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field