5 Host Organization Information Form

_{Host Organization Information Form}

1. Site Name: ____________

Street Address: _______________________________________________________

City: _____ State: Zip code:___________

2. Type of site (select the type that best describes your site):

O State Unit on Aging	O Multi-purpose social services organization
O Municipal Government
O Area Agency on Aging	O Recreational Organization
O State Health Department	O Residential Facility
O County Health Department	O Senior Center
O Educational Institution	O Other Community Center
O Faith-based Organization	O Tribal Center
O Health Care Organization	O Workplace
O Library	O Other (please specify):

3. Which falls prevention program(s) are you licensed to offer? [Note to Grantee: adapt this to fit local programming]

O A Matter of Balance	O YMCA Moving for Better Balance program
O Stepping On	O Tai Ji Quan: Moving for Better Balance
O Stay Active and Independent for Life	O Other—list name:

4. Contact Person’s Name and Information:

First and Last Name: _______________________________________________________

Daytime phone number: _________________________

Email address: _________________________________

Optional:

Title or role with organization:_______________________________________________

Role with the falls prevention program(s):______________________________________

Date trained in the falls prevention program: ___________________________________