2019/20 Program Member Renewal Questionnaire
PROGRAM & CONTACT INFORMATION
Enter coordinator or key program contact information.
Program Name *
Your answer
Coordinator First Name *
Your answer
Coordinator Last Name *
Your answer
Coordinator Email *
Your answer
Coordinator Phone Number *
Your answer
City/Town (in which program is located) *
Your answer
Other Communities Served by Program (city/town)
Your answer
Organization/Sponsoring Agency *
Your answer
Health Region *
PROGRAM INFORMATION
Total Number of Staff Employed by Progam *
Your answer
Total number of FTEs employed by the program *
Your answer
Who are your Funders? *
Required
Where do you provide your services? *
Required
Program offers outreach support to perinatal families at no cost: *
Program employs pregnancy outreach/peer support workers *
Program has access to a social worker? *
Program has access to a registered nurse? *
Program has access to a registered dietitian? *
CLIENT INFORMATION [January 1 - December 31, 2018]
How many prenatal intakes did your program have? *
Your answer
How many postnatal women are in your program? *
Your answer
How many women in your program self-identify as an Aboriginal person (First Nations, Inuit, or Metis)?
Your answer
How many women in your program are recent immigrants or are refugees?
Your answer
How many women in your program are living in poverty?
Your answer
How many women in your program have experienced violence/abuse?
Your answer
How many women in your program face geographical isolation?
Your answer
How many women in your program face substance use and/or addiction?
Your answer
MEMBERSHIP TERMS
Organization/individual is associated with delivery of perinatal services: *
I agree to support BCAPOP's mission (view at: www.bcapop.ca/Vision-&-Mission) *
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