Program Info Collection Form
Please submit your information via e-mail, regular postal mail or fax.
Today's Date: Director's Name: Program Name: Mailing Address: City: State: Zip Code: Country: E-mail address of contact person: (required)
Call Collect: Yes No Phone 1: Phone 2: Car Phone/Pager: Fax Number:
Phases or levels of program: Ages you accept: Which classification(s) best describes this type of program: Counseling Center Induction Center Residential Outpatient Referral Agency
Which of the following do you accept: Male Female Juvenile Battered Women Emotional Problems Pregnancy Crisis Runaways Sex Offenders Sodomites
Length of Program: Fee: Denominational Affiliation: Requests Preliminary Screening Application for Program Entry: Yes No Requests Missing Link newsletter subscription (free): Yes No Other Comments:
Print and complete the above form, and return it to The Missing Link, Inc.FAX:  960-1871
Regular Postal Mail:Director of Placement Services
The Missing Link, Inc.
P. O. Box 40031
Cleveland, OH 44140-0031 U.S.A.
Please send us a few brochures describing your program so we can use them for referral.
Linking Troubled Youth and Adults with Life-Changing Programs
Web site - http://misslink.org
Chapel Site: http://misslink.org/chapel2.html
Copyright © 2007 - The Missing Link, Inc. ®<Top of Page>
Last updated February 2007.