DEPARTMENT OF HUMAN SERVICES
Dakota at Home
On-line Resource Directory
Request for Inclusion
*Entity:
Entity Type:(Non-profit, goverment, for profit)
Description (Describe the primary services provided):
Main Phone: TDD/TTY No:
Main Website: Main Email:  
Days / Hours of Operation:
Primary Contact: Title:
Phone: Cell: Email:  
Address:
City: State: Zip:
Secondary Contact: Title:
Phone: Cell: Email:  
Address:
City: State: Zip:
Program/Site Location: (Please complete a separate form with applicable information for each program/site).
Street Address: Suite:
City: State: Zip:
Mailing Address:
City: State: Zip:
Phone: Fax:
Entity has been in business for at least six (6) months? Number of staff persons employed:
Bilingual staff available: Languages supported:
Physical location is wheelchair accessible: Explain:
Eligibility Requirements:
Who is eligible for your services?
Are services restricted to certain populations based on age, gender, income, family status, etc.?
Payment Source (check all that apply)

Cities served:
Counties served:
Zip Codes served:
Ages served:
 
* Completion of this form is not a guarantee of inclusion in the on-line Dakota at Home Resource Directory.
 
I attest that I have the authorization to provide the information on behalf of afore mentioned entity and the information is true and accurate to the best of my knowledge. I understand and agree that misrepresentation or omission of pertinent information regarding the entity and/or service(s) provided will result in the exclusion of the entity from the Dakota at Home Resource Directory database. Furthermore, it is acknowledged and understood that participation in the on-line Dakota at Home Resource Directory operated by the Department of Human Services does not constitute an endorsement of the entity by the South Dakota Department of Human Services.

*Name of Person completing Request:    Title: