Dss Form 3359 - Application For Participation Page 4
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923. The purpose of the emergency shelter program(s) is to provide temporary, residential care to
n
n
n
n
children in residence with their parents/guardians.
Yes
No
Civil Rights Information (Data should be expressed in actual numbers)
24. Ethnicity: Hispanic or Latino:
Not Hispanic or Latino:
Race:
American Indian or Alaskan Native:
Asian:
Black or African American:
Native Hawaiian or Other Pacific Islander:
White:
25. Describe efforts to be used to assure that minority populations have equal opportunity to participate.
26. Describe efforts to contact minority and grass roots organizations about the opportunity to participate in the program.
27. List the name(s) of other federal agencies providing assistance to your organization. Also state if you have been in
noncompliance by these federal agencies.
DSS Form 3359 (MAR 15)
PAGE 4
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