ACCESS!

Grand Rapids: Agency Sign-up Form

August 2013-July 2014
Agency Name: ___________________________________________________________________
Mailing Address:__________________________________________________________________
City, State, Zip:___________________________________________________________________
Website:
Staff Contact at Agency
(Person who will handle ticket requests)

Phone

E-mail

ext.

_______

Fax

PLEASE PRINT OR TYPE CLEARLY. All information must be completed and returned for
continued service. Please fill out completely - our funders require this information.
Primary County

_____Other Counties Served

Areas of Service Check all that apply:

____
____
____
____
____
____
____
____

Mental Health
Cognitive Disabilities
Substance Abuse/Recovery
Developmental Disability
Mobility Impairment
Blindness/Visual Impairment
Deafness/Hearing Impairment
Other: ______________________

_______
What was your total actual expenses for your
last completed fiscal year? ________________
What is your total budget for your current
fiscal year?_____________________________

Which is the primary area of service?

Number of People and Age Groups Served:

_______ Total number of people served yearly
_____% Adults ages 26+
_____% Adults between 19 and 26
_____% Youth between 7 and 18
_____% Youth between birth and 6
_____ % Male
_____ % Female
Page 1

Is your Agency a Non-Profit? _____Yes

_____No

****If no, please contact the Program Coordinator BEFORE completing this form.
Please add these additional staff e-mail addresses who would like to receive the ACCESS! Grand Rapids
Monthly Update. Only the official Agency Contact may make ticket requests.
Name:

___

Name:

Title: __________________
___ Title: ___________________

Email:

_______

Email:

_______

Agency Description briefly state the general purpose and goals of your agency what you do, not your mission
statement.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Demographic info Our funders require this information from us.

Of the total number of people served each year, what percent are:
_____ % Caucasian
_____ % African American
_____ % Hispanic
_____ % Asian American
_____ % Pacific American
_____ % Native American
_____ % Children with disabilities
_____ % Adults with disabilities

Agency Certification
We certify that the information included in this agency update is true and complete to the best of our
knowledge.
Agency Director

Staff Contact at Agency - handling requests

Signature ___________________________

Signature _____________________________

Name ______________________________

Name ________________________________

(Please print)

(Please print)

Date signed _________________________

Date signed ___________________________

Telephone _________________ Ext______

Telephone ___________________ Ext______

Page 2

ACCESS! Grand Rapids: Agency Invoice for August 2013-July 2014

For services through July 31, 2014

Agency Name: _____________________________________________

Please return a copy of this invoice with your payment & agency sign-up form.
A copy of this invoice ensures that your account is credited accurately.

Your Agency Budget for FY14 (must be 3rd party verifiable):

Amount Due:

$___________________________

$_____________________________________
(Use sliding scale below to determine fee)

If your Agency Budget Is

Your 2013/2014 Fee Is

Up to$50,000
$50,001.................$100,000
$100,001.$250,000
$250,001...............$500,000
$500,001$1,000,000
$1,000,001.$1,500,000
$1,500,001............$2,000,000
$2,000,001.$3,000,000
$3,000,001............$4,000,000
$4,000,001.......... and above

$50.00
$75.00
$170.00
$175.00
$280.00
$300.00
$446.00
$557.00
$667.00
$686.00

Make check payable to: Artists Creating Together

If paying by credit card, circle:
Name on Card

VISA

MasterCard

Signature

____

(Please print)

Card Number

Expiration Date_____________Zip Code _____________

Three or Four Digit Security Code:____________________(Located on the back of a Visa or Mastercard)

Submit completed form and Agency Invoice to ACT at:

Mail: 1140 Monroe Ave NW, Ste 4101, Grand Rapids, MI 49503
E-mail: coordinator@artistscreatingtogether.org
Fax: #616-885-5867
If you have any questions, please contact Becky Baker, ACT Program Coordinator at
#616-885-5866 or coordinator@artistscreatingtogether.org

ACCESS! Grand Rapids Sign-up form and Agency Invoice are adapted from VSA Georgias 2013-2014 Agency Update form and
Invoice for their Community Events program.