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Family Well-being Coalition Member Registration
After reviewing the Coalition
Terms of Reference
please complete the following intake form.
Once your form has been reviewed you will be followed up with. If you have questions please email community@westcoastleaf.org
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name:
*
Your answer
Pronouns i.e. she/her, he/him, they/them:
Your answer
Organization:
*
Your answer
Job Title:
Your answer
Address:
*
Your answer
City:
*
Your answer
Postal Code
*
Your answer
What region does your organization serve?
*
Your answer
How would you describe your organization/collective?
*
Indigenous Nation
Indigenous Non-profit
Family Support Non-profit
Legal Non-profit
Grassroots Group
Legal firm
Research-focused organization
Other:
What demographic of families does your organization serve (such as Indigenous families, young parent, immigrant families, grandparents raising grandchildren, low-income families, families in a geographic specific location, etc.)?
*
Your answer
Are there any accessibility needs we should be aware of for supporting your participation in the Coalition?
Your answer
Are you okay with your name (first and last) being shared with our funder Law Foundation?
*
Yes
No
Other:
Are you okay with your name (first name only) being shared in West Coast LEAF public-facing materials? i.e. listed as a volunteer in our annual report?
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Yes
No
Other:
Can we list your organization as a Coalition member on our webpage?
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Yes
No
Other:
We can offer a limited number of honorariums to support individuals and organizations to participate in the project. We are prioritizing those who are not paid to attend. Will you need to access an honorarium to participate?
*
Yes
No
We recommend that each organization assign an alternative member of their team to be a back up participant for the coalition, what is the name of the alternative person (if possible)?
*
Your answer
Would you like the alternate to be added to the Coalition email group, if yes please enter the email below:
Your answer
Having reviewed the
Coalition Terms of Reference
, do you agree to adhere to TOR?
*
Yes
No
Questions & Comments
Your answer
A copy of your responses will be emailed to the address you provided.
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