Membership

AHVNA Membership Form - Early Childhood Educators

Organization Non-Profit membership is for those organizations that...

Name of Program or Service: *

Name of Agency / Organization: *

Facility ID *

Phone: *

Fax:

Website / URL:

Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Contact Information

Note: This person will be able to make changes on the AHVNA website for your agency.

Contact Name: *

Role *

Phone:

Email *

Alternative Contact: *

Alternate Contacts Role *

Phone: *

Email: *

Membership Information

My organization is: *

Renewing an EXISTING membership
Applying for NEW membership

Would you or your organization be interested in participating with AHVNA in one of the following areas? (please check all that apply)

Board Member
Workshop Trainer (requires name and contact info.) e.g., Reflective Practice
Working Group Member (e.g., Aboriginal, Father Involvement, Family Violence, PICCOLO)

Agreements

Agree to receive email messages from AHVNA (CASL Requirement)

Agree to have our organizations information on a contact list provided to other AHVNA members

Agree to have our organizations information on the AHVNA website

Funding Sources

(please specify sources or funding body and percentage of budget):

Partners

(significant in-kind)

Description (e.g. office space)

Alberta Health Services

Other:

(please specify)

2. Alberta Children’s Services and Alberta Community & Social Services

If your agency is contracted with Alberta Children’s Services or Alberta Community & Social Services, what are your funding code(s)? Check all that apply.

Program Staffing: Current *FTE = Full Time Equivalent

How many staff do you estimate require training?

Description of Program/Service

Start date of program or service:

Service area:

(i.e., what communities do you serve)?

Nature of program participation:

Voluntary
Mandatory
Both

(e.g., if families are referred to your program under a Child Protection Order or Support Agreement, or through the Courts, nature of participation would be Mandatory.)

Other lengths families may stay involved?

Which ages does your program serve?

0-6 years
6-12 years
Both

Standardized Screening Tools in use when the family enters the program

(check all that apply)

Any other information / comments you wish to provide?

Membership Fee

Price: $100.00

Choose a Payment Method *

eTransfer
Cheque
Invoice

Total

$0.00

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Membership | Early Childhood Educators

Primary Contact Information

Membership Information

Agreements

Funding Sources

Partners

Description of Program/Service

Home Visitation

Training

Resources