Host Organization Information Form
1. Site Name: ____________
Street Address: _______________________________________________________
City: State: Zip code:___________ _____
State Unit on Aging
Municipal Government
2. Type of site (select the type that best describes your site):
Area Agency on Aging
State Health Department
County Health Department
Educational Institution
Faith-based Organization
Health Care Organization
Library
Multi-purpose social services
organization
Recreational Organization
Residential Facility
Senior Center
Other Community Center
Tribal Center
Workplace
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 Stepping On
O Stay Active and Independent for Life
O YMCA Moving for Better Balance program
O Tai Ji Quan: Moving for Better Balance
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: ___________________________________
