The Center for Faith & Community Health Transformation

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Organization Name

Faith Community, Organization, or Program Description

Street Address

Suite or Unit

City

State

Zip Code

E-mail Address

Contact Person Details

Contact Person

Phone

Mobile Phone

Fax

Who is eligible to participate?

What kind of services, programs or activities do you provide?

What does someone have to do to get involved?

Are you interested in partnering with others?

What kind of partners would you like to work with?

Is your facility accessible to people with disabilities as defined by the Americans with Disabilities Act (ADA)? yes no

Please provide your regular office hours and the days of the week your facility is open.

Organization Information (only if different from contact information)

Is your mailing address different that your physical address?

Mailing Address

Mailing Address line 2

Mailing City

Mailing State

Mailing Zip Code

Main Number

Fax Number

Toll Free Number

Alternate Numbers

Website

Emergency Preparedness/Disaster Response Readiness

Do you have emergency preparedness plans in place already?

Do you have contingency plans in case of building damage?

Do you have an evacuation plan?

Do you have emergency supplies (water, canned food, radio, batteries)?

Do you have a plan for outreach/communication with members in the event of an emergency?

Would you be willing to partner with public health departments in administering vaccines in time of public health crisis?

Do you have any facilities you would have to offer in case of an emergency or community disaster?

Do you have a van, bus or other transportation resources that would be available to transport people in a time of crisis?

Do you have any trained health professionals who could assist in medical interventions such as vaccinations or other procedures in such a time?

Do you have a corps of volunteers who can assist with tasks as needed—e.g. clean up, transportation, phone calls, etc.?

Service Areas (please select all that apply)

Health Topics (please select all that apply)

Organization Type

Religious Affiliation

Size of Congregation

Languages Spoken (please select all that apply)

Terms of Service *required

The information you include on this form will be made public on the Directory and Map of the chicagofaithandhealth.org website. Please indicate that you agree to have this information posted publically.

THE CENTER FOR FAITH AND COMMUNITY HEALTH TRANSFORMATION

A joint project of Advocate Health Care and the University of Illinois at Chicago Neighborhoods Initiative.

CONTACT

205 W. Touhy Ave., Suite 127 • Park Ridge, IL 60068 (847) 384-3552 • cfchtmail@gmail.com
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The Center for Faith & Community Health Transformation

Submit Directory Information

Contact Person Details

Organization Information (only if different from contact information)

Emergency Preparedness/Disaster Response Readiness

Service Areas (please select all that apply)

Health Topics (please select all that apply)

Organization Type

Religious Affiliation

Size of Congregation

Languages Spoken (please select all that apply)

Terms of Service *required

Submit Directory Information

Newsletter

Donations

THE CENTER FOR FAITH AND COMMUNITY HEALTH TRANSFORMATION

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