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            Required Information

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            Organization/Congregation Name:  
            Address:  
            City:   State:  select.... AL AK AS AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip:
            Phone Number:
            Organization/Congregation email:  
            Organization/Congregation web page:  
            Congregation's AAW Liaison*:  
            Liaison's Phone Number:  
            Liaison's email:  
            County of OKDHS Office:  

            *Person coordinating the Adopt A Worker program at the Faith-Based organization.

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            Other Information

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            OKDHS Phone Number:
            OKDHS AAW Program Contact (if any):
            Program Contact's email address:

            OKDHS Adopted Worker:

            Approximate Date of "Adoption":

            Program Comments: