6 Host Organization

Host Organization Information Form
1. Agency Name:
Street Address: _______________________________________________________
City:

State:

Zip code:___________

2. Type of agency (select the type that best describes your agency):
O State Unit on Aging
O Municipal Government
O Area Agency on Aging
O State Health Department
O County Health Department
O Educational Institution
O Faith-based Organization
O Health Care Organization
O Library

O Multi-purpose social services
organization
O Recreational Organization
O Residential Facility
O Senior Center
O Other Community Center
O Tribal Center
O Workplace
O Other (please specify):

3. Which falls prevention program(s) are you licensed/authorized to offer? [Note to Grantee: adapt this list
to fit local programming]
O A Matter of Balance
O Stepping On
O Otago
O Stay Safe, Stay Active
O Fallscape
O Tai Chi—list name:
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:

_