Survey & Form Center

2. 
4. Important

   To submit this form you do not have to sign in or create a Form Center account (above. However, you will have to complete the form in its entirety without the option to save your progress unless you do create an account.

6. Creating A Form Center Account
   » Form Center Creation Instructions

   Use this link for instructions about how to create a Form Center account. Creating an account will enable you to save your progress while filling out the form.

8. General Information
10. Organization's Name*
12. Program Name*
14. Organization's Main Address*
16. City*
17. State*
18. Zip Code*
20. Website Address*

    Use "N/A" if agency doesn't have a website.

22. Area(s) Of Focus*

    1. Bullying / Cyperbulling
    2. Child Abuse
    3. Counseling Services
    4. Diversion Program
    5. Domestic Violence
    6. Ex-Offender / Reentry Program
    7. Gang Violence
    8. Legal Services
    9. Parenting Programs
    10. School Attendance / Truancy
    11. STRIVIN'
    12. Suicide Prevention
    13. Teen-Dating Violence
    14. Victim Support Services
    15. Youth Employment
    16. Other Youth Services
    17. Other
24. You Chose "Other." Please Specify.*
26. Program Descriptions
28. Third-Person

    These summaries will be appearing on jacksoncountycombat.com. Therefore, it is important that they be written in third person, using the program's and agency's name. Summaries written in the first person ("we," "our," etec.) can lead to confusion in that visitors to the site might believe that COMBAT is directly operating your program.

30. Brief Summary*

    This is brief summary of your program (limit 1,000 characters) is for use on our website index pages, where space is limited.

32. In-Depth Description*

    There is no character limit for the detailed description you can provide here. You can likely take the description from your fundng application, though be sure to edit accordingly to eliminate any first-person references.

34. Program Contact Information & Locations

    This information will be published on the COMBAT website.

36. Phone*
37. email
39. Location(s)*

    Include the name of school, church, community center, etc. Also list specific phone for that location if different than the contact number provided above.

    SAMPLE:

    Irving Elementary School

    505 N. Elm Street, Kansas City, MO 64106

    816-123-4567

    
    

41. Other Contacts

    This information will not be published on our website, but email addresses will be added to our providers list for communications from COMBAT.

43. Agency Director*
44. Official Title*

    Director, Executive Director, President, etc.

46. email*
47. Phone*
49. Signature

51. By typing your name in the "Signature" box below, you acknowledge that this "electronic signature" is valid to the same effect of a traditional handwritten signature.

53. Signature*
54. Date*
    Date
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field