Agency Representative InformationThis information will not be shared publicly and will only be used if FAM staff needs to reach you with questions or clarification around the information provided on this form.Name(Required) First Last Phone(Required)Email(Required) Submit a calendar event: https://permanencyhubmn.org/events/community/add/This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.About Your AgencyThe information provided in this section of the form will appear on your the Resource Hub landing page for your agency or organization.Agency or Organization Name(Required)Main Office Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Main Office Phone(Required)General Contact Email(Required) Website(Required) Do you have additional office locations?(Required) Yes No Enter other locations (if applicable)Agency Intro/Description Paragraph(Required)Please only include information in this box if you need to update or change the intro paragraph on your agency’s resource hub landing page.”Communities Served through your PPPC or PSS Grant (check all that apply)(Required) Prospective/current foster parents Prospective/current adoptive parents Prospective/current kinship caregivers Foster or adopted children/teens Professionals Regions Served: (check all that apply)(Required) All Regions in Minnesota North West North Central North East West Central East Central South West Metro South East Other Other:DHS Contract Type (check all that apply): Public Private Permanency Collaboration (PPPC) Permanency Support Services Public Private Permanency Collaboration (PPPC) Services ProvidedExamples: Agency specific education, home studies, relative outreach, placement, child-specific recruitment, post adoption services, etc. Permanency Support Services ProvidedContract Type: (check all that apply): PPPC Permanency Support Services PPPC Services ProvidedExample: Pre-adoption education, support groups, home studies, relative home studies, child specific recruitment, post-adoption services, etc. Estimated Wait Time: N/A, 2 months, etc. PSS Services ProvidedEstimated Response Time: (Ex. 2-3 business days) Δ
