HomeMy Public PortalAbout211 Palm Beach/Treasure Coast Agreement" ' �� R t l L n k Y t l d i , T r c a ^ . v r e C o w t
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G e t C o n n e c t e d . G e t m s w e m
A F F I L I A T E A G R E E M E N T
T o e n s u r e c o n t i n u i t y o f c a r e a n d s u p p o r t t o c l i e n t s , 2 1 1 P a l m B e a c h / T r e a s u r e C o a s t e n t e r s i n t o t h e
f o l l o w i n g a g r e e m e n t w i t h :
T o w n o f G u l f S t r e a m
o r t y p e y o u r a g e n c y n a m e h e
2 1 1 P a l m B e a c h / T r e a s u r e C o a s t a g r e e s
C I C S 0 5 7 1
1 . T o r e f e r c a l l e r s , w h o m e e t t h e e l i g i b i l i t y r e q u i r e m e n t s ) o f t h e A f f i l i a t e , t o t h e A f f i l i a t e w i t h o u t
r e g a r d t o r a c e , c o l o r , c r e e d , d i s a b i l i t y , n a t i o n a l o r i g i n , a g e , s e x , s e x u a l o r i e n t a t i o n o r e c o n o m i c
s t a t u s f o r a s s e s s m e n t / o n - g o i n g s e r v i c e s .
2 . T o b e a v a i l a b l e a s a r e s o u r c e t o t h e A f f i l i a t e ' s c l i e n t s 2 4 h o u r s a d a y f o r t e l e p h o n e c o u n s e l i n g a n d
i n f o r m a t i o n a n d r e f e r r a l t o c o m m u n i t y r e s o u r c e s .
3 . T o b e a v a i l a b l e t o t h e a f f i l i a t e ' s s t a f f f o r i n f o r m a t i o n a b o u t a n d r e f e r r a l s t o c o m m u n i t y r e s o u r c e s .
T h e A f f i l i a t e a g r e e s :
1 . T o r e c e i v e c l i e n t s , w h o m e e t t h e e l i g i b i l i t y r e q u i r e m e n t s ) , w i t h o u t r e g a r d t o r a c e , c o l o r , c r e e d ,
d i s a b i l i t y , n a t i o n a l o r i g i n , a g e , s e x , s e x u a l o r i e n t a t i o n o r e c o n o m i c s t a t u s w h o a r e r e f e r r e d b y 2 1 1
P a l m B e a c h / T r e a s u r e C o a s t .
2 . T o a d v i s e c l i e n t s o f t h e 2 4 - h o u r a v a i l a b i l i t y o f 2 1 1 P a l m B e a c h / T r e a s u r e C o a s t s e r v i c e s .
3 . T o a d v i s e s t a f f o f t h e a v a i l a b i l i t y o f 2 1 1 P a l m B e a c h / T r e a s u r e C o a s t a s a r e s o u r c e .
4 . T o i n f o r m 2 1 1 P a l m B e a c h / T r e a s u r e C o a s t w h e n c h a n g e s a r i s e w i t h i n t h e A f f i l i a t e .
5 . T h a t i n f o r m a t i o n p r o v i d e d i s t r u e a n d a c c u r a t e t o t h e b e s t o f t h e i r k n o w l e d g e a n d t h a t t h i s
i n f o r m a t i o n m a y b e i n c l u d e d i n p u b l i s h e d m a t e r i a l s a n d i n l o c a l o r s t a t e w i d e d a t a b a s e s .
6 . T o p r o v i d e 2 1 1 P a l m B e a c h / T r e a s u r e C o a s t a y e a r l y f o r m a l u p d a t e w h e n r e q u e s t e d b e g i n n i n g a t
t h e s t a r t o f e a c h c a l e n d a r y e a r f o r a c c u r a c y , d e l e t i o n a n d n e w c o n t e n t . A g e n c i e s c a n u p d a t e
f o r m a l l y d u r i n g t h e y e a r u s i n g t h e o n l i n e u p d a t e p r o c e s s p r o a c t i v e l y o n t h e w e b s i t e .
T h i s l e t t e r o f a g r e e m e n t w i l l r e m a i n i n f o r c e u n t i l t e r m i n a t e d b y e i t h e r p a r t y c o n t i n g e n t u p o n t h i r t y ( 3 0 )
d a y s w r i t t e n n o t i c e .
2 1 1 P A L M B E A C H I f R E A S U R E C O A S T :
1 " ��
S u s a n K . B u z a , c e c u t i v e D i r e c t o r
J a n u a r y 2 , 2 0 1 5
D a t e S i g n e d
1 1 / 2 6 / 2 0 1 4
2 1 1 P a l m B e a c h T r e a s u r e C o a s t
A F F I L I A T E :
P a g e 4 o f 4
I n f o r m a t i o n f r o m 2 1 1 C o m m u n i t y R e s o u r c e D a t a b a s e
211 Palm Beach/Treasure Coast
PO Box 3588
Lantana, FL 33465
To: Judi Hechtman
Phone: (561) 383-2162
Email:judi.hechtman@21lpbte.org
Fax: (561) 383-2172
Date: 4-20-15
Pages: 2
211 Database Update
From:
Agency Name: Town of Gulf Stream
Contact Name: William H. Thrasher
Phone Number: 561-276-5116
I have reviewed the details of our agency/site(s)/service(s), and:
The information is correct x
We are enclosing corrections
Town of Gulf Stream
Agency #:
CICS0571
100 Sea Road
Last Formal Update:
4/14/2014
Gulf Stream, FL 33483
Record Owned By:
CICS
Mailing Address:
Date Entered:
11/5/2010
100 SEA RD
Affliliate Agreement Date:
4/14/2014
Gulf Stream, FL 33483
Notes/Description:
Municipal government. Commission meets 2nd
Phone Number EXT Dept/Contact
(561)276-5116
Agency County:
PALM BEACH
Also Known As:
Agency Type:
Municipal Government
Person In Charge:
William Thrasher
In Charge Title:
Town Manager
Email:
bthrasher@gulf-stream.org
Website:
www.gulf-stream.org
Hours of Operation:
9 A.M.-4 P.M.
Notes/Description:
Municipal government. Commission meets 2nd
Site Name: Gulf Stream Library
100 Sea Road
Gulf Stream, FL 33483
11/26/2014
211 Palm Beach Treasure Coast
Agency Fax
(561) 737-0188
Year Incorporated: 1925
IRS Status:
Agency FEIN:
License/Accred.:
Annual Budget: $0.00
Source of Funds:
Site ID: CICS0571AD
Last Formal Update: 4/14/2014
Page 1 of 4
Information from 211 Community Resource Database
Site Mailing Address:
100 SEA RD
Gulf Stream, FL 33483
Phone Number EXT Dept/Contact
(561)276-5116
Site Fax
561-737-0188
Please Complete this section and includelsend a copy of your AHCA License, if this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker and Companion Service, Nurse Registry
Facility/Provider Type:
License Number: License Expiration Date:
Also Known As:
Title:
Person In Charge:
William Thrasher
In Charge Title:
Town Manager
Site Email:
bthrasher@gulf-stream.org
Site Website:
www.gulf-stream.org
Site Hours:
Monday -Friday 19 am -4 pm
Notes/Description:
Service Intake Process: Walk-in registration.
Site Service ID: CICS004757
Program Name:
Documents Required:
Site Accessibility:
Site Bus Access:
Taxonomy Code Site Service Use Reference Terms
TJ -4400.6500 Public Libraries
Target Terms:
In Charge:
Title:
Service Phone: (561)276-5116
Ext: Phone 2: Fax: 561-737-0188
Site Service Email: bthrasher@gulf-stream.org
Site Service Website:
www.gulf-stream.org
Site Service Fees:
Free to residents and their guests.
Site Service Hours:
Monday -Friday 19 am -4 pm
Service Area:
Town of Gulf Stream
Service Intake Process: Walk-in registration.
Service Eligibility:
Residents and guests of residents of Gulf Stream. Services not available to non-residents.
Documents Required:
Language(s):
English.
Notes/Description:
11/26/2014
211 Palm Beach Treasure Coast
Page 2 of 4
Information from 211 Community Resource Database
Site (Location)
Site Name: Town of Gulf Stream Site ID: CICS0571AA
100 Sea Road Last Formal Update: 4/14/2014
Gulf Stream, FL 33483
Site Mailing Address:
100 SEA RD
Gulf Stream, FL 33483
Phone Number EXT Dept/Contact Site Fax
(561)276-5116
561-737-0188
Please Complete this section and include/send a copy of your AHCA License, if this site provides:
Adult Day Care, Family Care Home, ALF, Nursing Home, Home Health Agency, Homemaker and Companion Service, Nurse Registry
Facility/Provider Type:
License Number: License Expiration Date:
Also Known As:
Person In Charge: William Thrasher
In Charge Title: Town Manager Site Accessibility:
Site Email: bthrasher@gulf-stream.org Site Bus Access:
Site Website: www.gulf-stream.org
Site Hours: 9 A.M.-4 P.M.
Notes/Description: Municipal government. Commission meets 2nd Friday / 9 am.
Site Service ID: CICS004755
Program Name:
Taxonomy Code
TD -6600.4500
Target Terms:
Site Service
Local Officials Offices
In Charge: Wm. Thrasher
Service Phone: 561-276-5116 Ext: Phone 2:
Site Service Email: bthrasher@gulf-stream.org
Site Service Website: yam, gulf -stream. org
Site Service Fees: No fees charged.
Site Service Hours: 9 A.M. - 4 P.M.
Service Area: Gulf Stream
Service Intake Process: Contact by phone.
Service Eligibility: No restrictions.
Documents Required:
Use Reference Terms
City Government Offices
City Officials Offices
County Government Offices
County Officials Offices
Municipal Government Offices
Town Government Offices
Title: Town Manager
Rx: 561-737-0188
Language(s): English.
Notes/Description: Municipal government. Commission meets 2nd Friday / 9 am.
11/26/2014
211 Palm Beach Treasure Coast
Page 3 of 4
Information from 211 Community Resource Database
tblm 9eocty Reosure Coast*
Get Connected. GetAnswem
AFFILIATE AGREEMENT
To ensure continuity of care and support to clients, 211 Palm Beach/Treasure Coast enters into the
following agreement with:
Town of Gulf Stream
(Print or type your agency name
211 Palm Beach/Treasure Coast agrees:
CICS0571
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 assessment/on-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 requirements), 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:
Susan K. Bu a, Executive Director
January 3, 2014
Date Signed
11/18/2013
211 Palm Beach Treasure Coast
AFFILIATE: _
L �l
Date Signed
Page 4 of 4
Information from 211 Community Resource Database
Transmission Report
Date/Time 04-14-2014 11:35:02 a.m. Transmit Header Text
Local ID 1 5617370188 Local Name 1
This document: Confirmed
(reduced sample and details below)
Document size : 8.5 rrx11 "
Fax Cover Sheet
211 Palm Beachn...re coast
PO Be. 7988
Leman, FL 33489
To: Judi HechUran
Phonc: (5611 383-2162
Small: IudlhachManQ2/ 1pbW.og
Fac (VII 3.1172
Data: Pages:
From:
Agency Name:
`— 1
Contact Name:
PhoneNumber.
I heve re erwed the details of our egencyhi[e(eNeervice(e), and:
The Informed. is correct
We are enclosing cMBcnW6
Fax
-,1PI 131-0 }(
Argent, County: PALM BEACH Yaarinearmeatad:
Area Known As: IRS Status:
Agency Type: Municipal Gvyemmanl Agency FEIN:
Person In Charge: yWBam Thrasher llcensWAccm&:
In Charge Tide: Town Manager Annual Budget So.00
Snail: blhrasher®gulf-dream org Sourceaf Furtls:
WeMite: were gulf-seram.og
Haum ofopemdon: A_MTA, --.SfC1 r -N
NotealD,scdpdan: Municipal gvvemmem. jamalrmeets 2nd Friday/gem
Slue Name: Gulf Stream Library Site 10: CIS0571AD
100 Saa Road Lust Formal Update: 211 e2013
GUN Stream, FL 33483
11/182013 Page 1074
211 Peen Bead, T.. Coad idmmnad. Gem 211 Cunvmnily Re. Database
Total Pages Scanned: 4 Total Pane%rnnf(rmnd•d
No. Job Remote Station StartTlme Duratlon Pages Line I Mode jJobType I Results
001 1826 13832172 11:32:11 a.m. 04-14-2014 00:02:21 1414 11 1 EC IHS ICP14400
Abbreviations:
H5: Hort send PL: Polled local MP: Mailbox print CP: Completed T5: Terminated by system
HR: Host receive PR: Polled remote RP: Report FA: Fall G3: Group
WS: Waiting send MS: Mailbox save FF: Fax Forward TIJ: Terminated by user EC: Error Correct
Town of Gulf Stream
Agency B: CICS0571
100 Sea Road
Last Fomu1 Update: 21111!2013
GUN Stream, FL 334113
Rxord Owned By: CICS
Maling Address:
Date Entered: 111S2010
100 SFA RD
ANill,ele Agn enerm Dab: g2g2o0S
GuNSimam FL 33483
Phanc Number EXT DepdCormid
Agency Fax
(561) 276-5116
-,1PI 131-0 }(
Argent, County: PALM BEACH Yaarinearmeatad:
Area Known As: IRS Status:
Agency Type: Municipal Gvyemmanl Agency FEIN:
Person In Charge: yWBam Thrasher llcensWAccm&:
In Charge Tide: Town Manager Annual Budget So.00
Snail: blhrasher®gulf-dream org Sourceaf Furtls:
WeMite: were gulf-seram.og
Haum ofopemdon: A_MTA, --.SfC1 r -N
NotealD,scdpdan: Municipal gvvemmem. jamalrmeets 2nd Friday/gem
Slue Name: Gulf Stream Library Site 10: CIS0571AD
100 Saa Road Lust Formal Update: 211 e2013
GUN Stream, FL 33483
11/182013 Page 1074
211 Peen Bead, T.. Coad idmmnad. Gem 211 Cunvmnily Re. Database
Total Pages Scanned: 4 Total Pane%rnnf(rmnd•d
No. Job Remote Station StartTlme Duratlon Pages Line I Mode jJobType I Results
001 1826 13832172 11:32:11 a.m. 04-14-2014 00:02:21 1414 11 1 EC IHS ICP14400
Abbreviations:
H5: Hort send PL: Polled local MP: Mailbox print CP: Completed T5: Terminated by system
HR: Host receive PR: Polled remote RP: Report FA: Fall G3: Group
WS: Waiting send MS: Mailbox save FF: Fax Forward TIJ: Terminated by user EC: Error Correct
11/182013 Page 1074
211 Peen Bead, T.. Coad idmmnad. Gem 211 Cunvmnily Re. Database
Total Pages Scanned: 4 Total Pane%rnnf(rmnd•d
No. Job Remote Station StartTlme Duratlon Pages Line I Mode jJobType I Results
001 1826 13832172 11:32:11 a.m. 04-14-2014 00:02:21 1414 11 1 EC IHS ICP14400
Abbreviations:
H5: Hort send PL: Polled local MP: Mailbox print CP: Completed T5: Terminated by system
HR: Host receive PR: Polled remote RP: Report FA: Fall G3: Group
WS: Waiting send MS: Mailbox save FF: Fax Forward TIJ: Terminated by user EC: Error Correct
Abbreviations:
H5: Hort send PL: Polled local MP: Mailbox print CP: Completed T5: Terminated by system
HR: Host receive PR: Polled remote RP: Report FA: Fall G3: Group
WS: Waiting send MS: Mailbox save FF: Fax Forward TIJ: Terminated by user EC: Error Correct
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
Fa7111
}I 1) 3 3-2172 C
Date: Pages: I
From: `n
Agency Name: lw� T UA
Contact Name:
Phone Number:Ol'��O-5�1�
I have reviewed the details of our agency/site(s)/service(s), and:
The information is correct
We are enclosing corrections %Q
Town of Gulf Stream Agency #: CICS0571
100 Sea Road Last Formal Update: 2/18/2013
Gulf Stream, FL 33483 Record Owned By: CICS
Mailing Address: Date Entered: 11/5/2010
100 SEA RD Affliliate Agreement Date: 9/29/2009
Gulf Stream, FL 33483
Phone Number EXT Dept/Contact
(561)276-5116
Agency County:
Also Known As:
Agency Type:
Person In Charge:
In Charge Title:
Email:
Website:
PALM BEACH
Municipal Government
William Thrasher
Town Manager
bthrasher@gulf-stream.org
www.gulf-stream.org
Hours of Operation: ED t nyyit Z Q) r N
Notes/Description: Municipal government. gA m:Tmeets 2nd Friday / 9 am.
Site Name: Gulf Stream Library
100 Sea Road
Gulf Stream, FL 33483
11/18/2013
211 Palm Beach Treasure Coast
Agency Fax
IRA- -13-1-
Year Incorporated:
IRS Status:
Agency FEIN:
License/Accred.:
Annual Budget: $0.00
Source of Funds:
Site ID: CICS0571AD
Last Formal Update: 2/18/2013
Page 1 of 4
Information from 211 Community Resource Database
Site Mailing Address:
100 SEA RoD
Gulf Stream. FL 33483
Phone Number EXT Dept/Contact Site Fax
(561)276-5116
Please Complete this section and include/send a copy of your AHCA License if 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:
In Charge Title:
Site Email:
Site Website:
Site Hours:
Notes/Description:
William Thrasher
Town Manager
bthrasher@gulf-stream.org
www.gulf-stream.org
Monday -Friday / 9 am -4 pm
Site Service ID: CICS004757
Program Name:
Taxonomy Code Site Service
TJ -4400.6500 Public Libraries
Target Terms:
In Charge:
Service Phone: (561) 276-5116 Ext: Phone 2:
Site Service Email:
bthrasher@gulf-stream.org
Site Service Website:
www,gulf-stream.org
Site Service Fees:
Free to residents and their guests.
Site Service Hours:
Monday -Friday / 9 am -4 pm
Service Area:
Town of Gulf Stream
Service Intake Process: Walk-in registration
Site Accessibility:
Site Bus Access:
Title:
Fax:
Service Eligibility: Residents and guests of residents of Gulf Stream. Services not available to non-residents.
Documents Required:
Language(s): English.
Notes/Description:
11/18/2013
Page 2 of 4
211 Palm Beach Treasure Coast Information from 211 Community Resource Database
iratir
Site' Name. Town of Gulf Stream Site ID: CICS0571AA
100 Sea Road Last Formal Update: 2/18/2013
Gulf Stream, FL 33483
Site Mailing Address:
100 SEA RD
Gulf Stream, FL 33483
Phone Number EXT Dept/Contact Site Fax
(561)276-5116
Please Complete this section and include/send a copy of your AHCA License, if 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:
William Thrasher
In Charge Title:
Town Manager Site Accessibility:
Site Email:
bthrasher@gulf-stream.org Site Bus Access:
Site Website:
Site Hours:mtg�1�
t\
Notes/Description:
Municipal government.,Coarrctl'Ineets 2nd Friday / 9 am.
Site Service ID: CICS004755
Program Name:
Taxonomy Code
Site Service
TD -6600.4500
Local Officials Offices
Target Terms:
In Charge: Title:
Service Phone: Ext: Phone 2:
Site Service Email: bthrasher@gulf-stream.org
Site Service Website:
Site Service Fees:
Site Service Hours:
Service Area: Gulf Stream
Service Intake Process:
Service Eligibility:
Documents Required:
Language(s):
Notes/Description:
11/18/2013
English.
Municipal government.,Qaw,4c meets 2nd Friday / 9 am.
con y�yOYl.
211 Palm Beach Treasure Coast
Fax:
Page 3 of 4
Information from 211 Community Resource Database