Stark/Portage Community MARC Data Entry Form

If you represent an organization or agency that provides a service to K-12 schools in Stark or Portage County, please either:

• fill out this online form, and submit using the button at the end of the form, or

• print this form, fill it in using a dark pen (use additional paper if necessary) and fax or mail it to:

  East Central OH Area Media Center
  2100 38th Street NW
  Canton, OH 44709
  (FAX) 330.492.6175

  If you are uncertain how to fill out a certain section, simply put a question mark (?) in that space and we will contact you to assist you. Make sure you include a phone number and contact name in the appropriate spaces.

  How to Fill Out this Form

  Fill out each section as completely as possible. When you are done, click on the button at the bottom of the form that says "Submit." If you make a mistake, use the backspace key to erase and retype your entry. If you make several mistakes, you can clear the form by clicking on the button at the bottom of the form that says "Clear this form and start over," but you will clear all of your entries by doing this. Make sure to provide as much information in each section as you can. We will call to confirm or request additional information if necessary.

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  Name of Organization:

  Attention (for Mailing Purposes):

  Address and phone information

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  Primary Street Address:

  City:

  State:

  Zip:

  Toll Free Phone Number:

  Phone Number:

  Fax Number:

  Email Address:

  Web Site:

  TDD or TTY Phone Number:

  Contact Person:

  Title of Contact:

  If you have an additional address or phone number, please provide it here.

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  Secondary or Additional Street Address:

  Additional Address City:

  Additional Address State:

  Additional Address Zip:

  Additional Phone Number:

  Describe times of availability of services and/or meeting facilities.

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  List days and hours of operation:

  Describe meeting rooms and facilities available, if applicable:

  If applicable, describe equipment available:

  Describe your organization and its services

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  Describe your organization:
  

  Describe types of students and/or teachers served by your organization:

  If you do not serve all of Stark and Portage County, describe the geographic area served:

  Are there fees for your services? If so, what are they?

  How do teachers or students obtain your services (e.g. phone, walk-in, referral)?

  Please provide other information, if applicable, in the following spaces.

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  Languages, if any in addition to English, spoken by organization staff:

  Name of owner, director, or other person in charge:

  Does the organization accept students or teachers as volunteers?

  Does the organization provide volunteers to schools?

  Are there special requirements for volunteers?

  If this listing is for an individual, what are his or her credentials? (licenses, degrees, years of experience, etc.)

  List any special accommodations provided for the disabled?

  Name of organization publications, if any?

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