HomeMy WebLinkAboutAgreement_General_02/19/2013 Polrn Beach, rrevsure CoGSt
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AFFILIATE AGREEMENT
To ensure continuity of care and support to clients, 211 Palm Beach/Treasure Coast enters into the
following agreement with:
Village of Tequesta C
(Print or type your agency name here.)
211 Palm Beach/Treasure Coast agrees:
1. To refer callers, who meet the eligibility requirement(s) of the Affiliate, to the Affiliate without
regard to race, color, creed, disability, national origin, age, sex, sexual orientation or economic
status for assessmentlon -going services.
2. To be available as a resource to the Affiliate's clients 24 hours a day for telephone counseling and
information and referral to community resources.
3. To be available to the affiliate's staff for information about and referrals to community resources.
The Affiliate agrees:
1. To receive clients, who meet the eligibility requirement(s), without regard to race, color, creed,
disability, national origin, age, sex, sexual orientation or economic status who are referred by 211
Palm Beach /Treasure Coast.
2. To advise clients of the 24 -hour availability of 211 Palm Beach/Treasure Coast services.
3. To advise staff of the availability of 211 Palm Beach /Treasure Coast as a resource.
4. To inform 211 Palm Beach/Treasure Coast when changes arise within the Affiliate.
5. That information provided is true and accurate to the best of their knowledge and that this
information may be included in published materials and in local or statewide databases.
6. To provide 211 Palm Beach /Treasure Coast a yearly formal update when requested beginning at
the start of each calendar year for accuracy, deletion and new content. Agencies can update
formally during the year using the online update process proactively on the website.
This letter of agreement will remain in force until terminated by either party contingent upon thirty (30)
days written notice.
211 PALM BEACH /TREASURE COAST: AFFILIATE:
Susan K. Buza,�Executive Director
January 4, 2013
Date Signed Date Signed
11/16/2012 Page 5 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
Fax Cover Sheet
211 Palm Beach /Treasure Coast
PO Box 3588
Lantana, FL 33465
To: Judi Hechtman
Phone: (561) 383 -2162
Email: judi.hechtman @211pbtc.org
Fax: (561) 383 -2172
Date: Pages:
From: ' l
Agency Name: I/,f V % l L (� 7 ]
Contact Name: �i Ch a e Z,2
Phone Number: (% / — '26 — 0 7C d
I have reviewed the details of our agency /site(s) /service(s), and:
The information is correct
We are enclosing corrections k,
Village of Tequesta Agency #: CICS1317
345 Tequesta Drive Last Formal Update: 1/25/2012
Tequesta, FL 33469 Record Owned By: CICS
Date Entered: 11/5/2010
Mailing Address:
345 TEQUESTA DR Affliliate Agreement Date: 5/5/2005
Tequesta, FL 33469
Phone Number EXT Dept/Contact Agency Fax
(561) 768 -0460 (561) 768 -0697
Agency County: PALM BEACH Year Incorporated:
Also Known As: IRS Status:
Agency Type: Municipal Government Agency FEIN:
Person In Charge: Michael R. Couzzo, Jr. License /Accred.:
In Charge Title: Village Manager Annual Budget: $0.00
Email: mcouzzo @tequesta.org Source of Funds:
Website: www.tequesta.org/
Hours of Operation: Monday- Friday / 8:30 am -5 pm
Notes /Description: Municipal government. Council meets 2nd Thursday / 7 pm.
Site (Location)
Site Name: Tequesta Fire Department Site ID: CICS1317AC
357 Tequesta Drive Last Formal Update: 1/25/2012
Tequesta, FL 33469
11/16/2012 Page 1 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
Site Mailing Address:
PQ BOX 8 - 2 : 7-a 35 - 1 1 e�L-est
Tequesta, FL 33469 -3273
Phone Number EXT Dept/Contact Site Fax
( ) -911 TO REPORT AFIRE SW — TA - CVO
(561) 768 -0550
Please Complete this section and include /send a copy of your AHCA License if this this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker andCompanion Service, Nurse Registry
Facility /Provider Type:
License Number: License Expiration Date:
Also Known As:
Person In Charge: James Weinand
In Charge Title: Fire Chief Site Accessibility:
Site Email: Site Bus Access:
Site Website: W U)U', tel +a • 0 ( - 0
Site Hours: 24 Hours A Day / 7 Days A Week
Notes /Description: Local number to contact an individual fire department.
TO REPORT A FIRE, DIAL 911.
Site Service ID: CICS010709
Program Name:
Taxonomy Code Site Service
JR- 1900.2000 Fire Control /Extinction
Target Terms:
In Charge: Title:
Service Phone: Ext: Phone 2: Fax:
Site Service Email:
Site Service Website:
Site Service Fees: No fees charged.
Site Service Hours: 24 Hours A Day / 7 Days A Week
Service Area: Village of Tequesta
Service Intake Process: Contact by phone.
Service Eligibility: No restrictions.
Documents Required:
Language(s): English.
Notes /Description: Local number to contact an individual fire department.
TO REPORT A FIRE, DIAL 911.
11/16/2012 Page 2 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
Site )
Site Name: Tequesta Police Department (Location Site ID: CICS1317AA
357 Tequesta Drive Last Formal Update: 1/25/2012
Tequesta, FL 33469
Site Mailing Address:
Re BGX 32:7 351
Tequesta, FL 33469 -3273
Phone Number EXT Dept/Contact Site Fax
(561) 768 -0500 (561) 768 -0695
Please Complete this section and include /send a copy of your AHCA License if this this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker andCompanion Service, Nurse Registry
Facility /Provider Type:
License Number: License Expiration Date:
Also Known As:
Person In Charge: rn C hri Berl er 0(
In Charge Title: Police Chief Site Accessibility:
Site Email: Site Bus Access:
Site Website: Lk) v-) , J ve —s+cc . o
Site Hours: 24 Hours /7 Days A Week J
Notes /Description: Local law enforcement agency.
Site Service ID: CICS010707
Program Name:
Taxonomy Code Site Service
FL -6500 Municipal Police
Target Terms:
In Charge: Title:
Service Phone: Ext: Phone 2: Fax:
Site Service Email:
Site Service Website:
Site Service Fees: No fees charged.
Site Service Hours: 24 Hours /7 Days A Week
Service Area: Tequesta
Service Intake Process: Call.
Service Eligibility: No restrictions.
Documents Required:
Language(s): English.
Notes /Description: Local law enforcement agency.
11/16/2012 Page 3 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
i Site (Location)
Site Name: Village of Tequesta Site ID: CICS1317AB
345 Tequesta Drive Last Formal Update: 1/25/2012
Tequesta, FL 33469
Site Mailing Address:
345 TEQUESTA DR
Tequesta, FL 33469
Phone Number EXT Dept/Contact Site Fax
(561) 768 -0700 (561) 768 -0697
Please Complete this section and include /send a copy of your AHCA License if this this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker andCompanion Service, Nurse Registry
Facility /Provider Type:
License Number: License Expiration Date:
Also Known As:
Person In Charge: Michael R. Couzzo, Jr.
In Charge Title: Village Manager Site Accessibility:
Site Email: Site Bus Access:
Site Website: W LOW • +e j u.�e_S A • or
Site Hours: Monday- Friday / 8:30 am -5 pm
Notes /Description: Municipal government. Council meets 2nd Thursday / 7 pm.
Site Service ID: CICS010708
Program Name:
Taxonomy Code Site Service
TD- 6600.4500 Local Officials Offices
Target Terms:
In Charge: Title:
Service Phone: Ext: Phone 2: Fax:
Site Service Email:
Site Service Website:
Site Service Fees: No fees charged.
Site Service Hours: Monday- Friday / 8:30 am -5 pm
Service Area: Village of Tequesta
Service Intake Process: Contact by phone.
Service Eligibility: No restrictions.
Documents Required:
Language(s): English.
Notes /Description: Municipal government. Council meets 2nd Thursday / 7 pm.
11/16/2012 Page 4 of 5
211 Palm Beach Treasure Coast Information from 211 Community Resource Database