Membership

AHVNA Membership Form - Organization Non-Profit

Organization Non-Profit membership is for those organizations that are not for profit who would like be a part of the Alberta Home Visitation Network Association. (includes other FRN spokes that are not Home visitation spokes)

Name of Program or Service:

Name of Agency / Organization:

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

Description of Program/Service

Complete this section if your program provides direct service to families.

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.)

How long may families stay involved?

(check all that apply)

Standardized Screening Tools in use when the family enters the program

(check all that apply)

What outcomes do you measure?

Child development (parents have knowledge & understanding)
Healthy pregnancy and birth outcomes
Parent-child interaction
Positive parenting skills (parents have increased knowledge of effective parenting strategies)
Increasing protective factors and decreasing risk factors (parents provide safe & nurturing environments for their children)
Connections to community (families access formal/informal community services)
Basic needs (housing, food, clothing)
N/A
Other

(check all that apply)

Any other information / comments you wish to provide?

Membership Fee

Price: $100.00

Choose a Payment Method *

PayPal / Credit Card
eTransfer
Cheque
Invoice

Total

$0.00

Save and Resume Later

Complete the membership application form and pay online with a credit card or send it with your cheque to:

AHVNA
#170, 14315-118 Avenue
Edmonton, AB
T5L 4S6

Cheques are made payable to Alberta Home Visitation Network Association

Membership | Organization Non-Profit

Primary Contact Information

Membership Information

Agreements

Funding Sources

Partners

Description of Program/Service

Home Visitation

Training

Resources