Parent Mentor Program of Saskatchewan Parent Application

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Parent Mentor Program of Saskatchewan Parent Application"

Transcription

1 Parent Mentor Program of Saskatchewan Parent Application Name: Date of Birth: Partner s Name: Date of Birth: Address: Postal Code: Telephone Home: Work: Cell: School: Name: Date of Birth Family Tree: Partner s Name: Date of Birth Children s Names Birth date and Ages Male/Female Address: Postal Code: Education: Telephone Home: Work: School Employment: Number: Can we leave a message? If pregnant, what is your due date? Work Number: Can we leave a message? Parent Mentor Program of Moose Jaw, Saskatchewan 1

2 Education: Employment: All about you and other neat stuff: What special interests or talents do you have? How would you describe yourself? If you had a whole day just to yourself what would you do? What are some of the reasons you would like to participate in the Parent Mentor Program? Parent Mentor Program of Moose Jaw, Saskatchewan 2

3 What do you expect to gain from this program? Are there special skills you would like to develop? (i.e. parenting, communication, budgeting, education, self-esteem etc.) Do you have support people in the community? (ie partner, parents, church, friends etc?) What are the specific qualities, skills or attitudes you would like to see in your mentor? Who was/is a positive person in your life? Why? Parent Mentor Program of Moose Jaw, Saskatchewan 3

4 If you have a partner (boyfriend, married, common law) please provide his name: What is the highest level of education you have completed? Do you want to continue your education? Yes No What do you usually do in your spare time? Watch TV/movies visit write listen to music Crafts art read spend time with animals Exercise computer other What would you like to do if you had more spare time? What are you good at? (What do you think and what do other people say) What do you like about yourself? Is there anything you would like to change about yourself? What is your biggest challenge being pregnant and or parenting? What is your biggest overall life challenge? Do you have a driver s license? No Learners License Parent Mentor Program of Moose Jaw, Saskatchewan 4

5 Do you have access to a vehicle? Yes No What transportation is available to you? Ride Bus Cab Walk Bike How did you hear about Parent Mentoring Program? Public Health Nurse Social Worker Family Member Friend Counselor Doctor Poster/Pamphlet Television/Radio Teacher Other Why do you want to participate in PMP? What kind of assistance from a mentor and/or the SMSP program would you find most helpful? New skills New Information Groups A role model A supportive friend Referrals to other services Relationships Resources (books, tapes, With peer s videos, online information) What do you hope to gain from participating in PMP (check as many as apply): PREGNANCY INFORMATION: learning about what is healthy for me and my baby PARENTING SKILLS: learning normal growth, development and behavioral expectations of children PERSONAL ENHANCEMENT: learning problem solving, assertiveness & decision making skills as well as increasing self-esteem and self-confidence Parent Mentor Program of Moose Jaw, Saskatchewan 5

6 FINANCIAL: assistance with budgeting (establishing priorities, planning for payment of debt, bills & purchases) EDUCATION: guidance with current education or seeking alternative educational opportunities EMPLOYMENT: help in relationship with employer and/or co-workers, preparation of resume, coaching for interviews HOMEMAKING/HOUSEKEEPING: guidance and assistance in developing skills in managing a home i.e. cleaning, organizing HOUSING: help finding a new place to live and making arrangements to move TRANSPORTATION: assist with making arrangements to get to appointments such as the doctor, job interview, etc. (mentor may occasional drive parent if willing and available) NUTRITION: shopping for food, information regarding nutrition, meal planning and preparation RECREATION: participating with and encouraging fun and leisure activities. RELATIONSHIP CONCERNS: help in exploring thoughts and feelings about significant others in your life (partner, parents, children, extended family, friends) and your part in these relationships; referring for counseling or groups if wanted ADVOCACY: support and advice regarding contact with organizations, departments, agencies, etc CHILD CARE: assistance and support in determining child care needs (babysitter, daycare) What type of person do you picture your mentor to be? (Age, religion, race, personality, etc.) Parent Mentor Program of Moose Jaw, Saskatchewan 6

7 How many hours each week would you expect to spend with a mentor? What days of the week and time of day would work best for you? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning afternoon evening How have you been feeling lately? Very Good Good Okay Bad Very Bad How is your healthy, generally? Very Good Good Okay Bad Very Bad Do you have any chronic illnesses: Yes No If yes, please explain Do you have any allergies: Yes No If yes, please explain Are you taking any prescribed mediations (include birth control): Yes No If Yes, please explain Do you smoke cigarettes Do you drink alcohol Do you take drugs Yes Yes Yes No No No If yes to any of the above, do you want to quit: Yes No If yes do you want help to quit: Yes No Parent Mentor Program of Moose Jaw, Saskatchewan 7

8 Is there anything else you would like us to know that we have not asked or that you think we should know? Do you know of anyone, other than yourself, who would be interested in participating in the Parent Mentor program, as a parent or volunteer? Name Telephone Number Name Telephone Number As a participant in the Parent Mentor Program, I understand and agree to: 1. Code of confidentiality 2. Attend all activities. If I am unable to attend I will notify my Mentor and/or the Parent Mentor Program Coordinator. 3. I acknowledge that the Parent Mentor Program is under no obligation to accept or match me with a mentor. All information and files are the property of the Moose Jaw Parent Mentor Program. Date Signature Parent Mentor Program of Moose Jaw, Saskatchewan 8

Note: applicants must be a Permanent Resident to be eligible to volunteer at the City of Bayswater.

Note: applicants must be a Permanent Resident to be eligible to volunteer at the City of Bayswater. APPLICATION FOR REGISTRATION AS A VOLUNTEER Title: Mr / Mrs / Ms / Miss Name: (please also list preferred name for volunteer badge) J:\COMMUNITY SERVICES\ADMINISTRATI ON\VOLUNTEERS\Forms\ Application Forms\CURRENT

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT An Equal Opportunity/Affirmative Action Employer, the City of Dallas does not discriminate in employment with regard to race, color, sex, marital status, age, religion, national

More information

Life Coach Role Description

Life Coach Role Description Life Coach Role Description The Mentoring Plus program helps to empower youth in our community to make positive life choices that enable them to maximize their potential. Mentoring Plus uses adult volunteers

More information

Intake Assessment Christina Branco Psychotherapy 308 Wellington St, Kingston ON K7K 7A

Intake Assessment Christina Branco Psychotherapy 308 Wellington St, Kingston ON K7K 7A Intake Assessment Christina Branco Psychotherapy 308 Wellington St, Kingston ON K7K 7A8 613.329.7400 Name: Date of Birth: Family of Origin History: (*please include yourself in this table) Family Member

More information

Tipton County Public Library Volunteer Program Policy

Tipton County Public Library Volunteer Program Policy Volunteer Program Policy Purpose The library Volunteer Program is designed to provide enrichment of the library s mission and programs. Volunteers do not replace paid staff; rather, they support the services

More information

Relationship to volunteer applicant:

Relationship to volunteer applicant: Bristol Hospital Junior Volunteer Program Parental Consent Form In order for your child to become a volunteer with us, we need your consent and your involvement in helping them have a productive experience.

More information

Thank you for your interest in volunteering with St. Michael s Hospital!

Thank you for your interest in volunteering with St. Michael s Hospital! Thank you for your interest in volunteering with St. Michael s Hospital! St. Michael s Hospital could not realize its mission and vision without volunteers. Volunteers serve in units and departments throughout

More information

Contact: Barbara McIntosh Telephone: 07801290575 Email: bmcintosh@fpld.org.uk.

Contact: Barbara McIntosh Telephone: 07801290575 Email: bmcintosh@fpld.org.uk. Personal Planning Book The Personal Planning Book was originally written by Barbara McIntosh and Andrea Whittaker. Several revisions and additions to this book have been made since the original version

More information

aluable for all you are and all you do. O pen to trying new things. L oyal and reliable day after day. U ntiring in your willingness to help.

aluable for all you are and all you do. O pen to trying new things. L oyal and reliable day after day. U ntiring in your willingness to help. TEEN VOLUNTEER APPLICATION 6900 North Durango Drive 2075 E. Flamingo Road 5400 Rainbow Boulevard Las Vegas, NV 89149 Las Vegas, NV 89119 Las Vegas, NV 89118 (702) 835-9861 (702) 369-7782 (702) 853-3059

More information

Classes begin Monday, August 29 th, 2016 3-year-old class

Classes begin Monday, August 29 th, 2016 3-year-old class Please return completed packets to the church office, along with a $25 registration fee. Checks can be made payable to First Christian Church, with Bright Beginnings in the memo. Classes begin Monday,

More information

VOLUNTEER & WORK EXPERIENCE APPLICATION FORM

VOLUNTEER & WORK EXPERIENCE APPLICATION FORM VOLUNTEER & WORK EXPERIENCE APPLICATION FORM What is Deen City Farm? Based in the heart of South West London, Deen City Farm is one of the capital s oldest community farms. Spread over 5 acres and home

More information

Unique Visits. Returning Visits Total 1,538 1, Average Unique Visits

Unique Visits. Returning Visits Total 1,538 1, Average Unique Visits Side 1 af 9 30-10- 15:11:04 30 October Summary Log: No Limit Total 1,538 1,186 771 415 Average 5 4 3 1 Day Date Sunday 30th October 7 3 3 0 Saturday 29th October 2 1 0 1 Friday 28th October 2 2 1 1 Thursday

More information

BOARDING SCHOOL APPLICATION

BOARDING SCHOOL APPLICATION BOARDING SCHOOL APPLICATION Educatius International 22 Batterymarch Street Boston, MA 02109 Phone: 617-292-0035 Fax: 617-292-0053 Email: fullboardingapp@educatius.org TO THE SCHOOL: THIS APPLICATION IS

More information

Adult Volunteer Application

Adult Volunteer Application Adult Volunteer Application Thank you for your interest in s Volunteer Program. Volunteers play an important part in our hospital s effort to deliver quality healthcare to the children of East Tennessee,

More information

TEEN VOLUNTEER APPLICATION

TEEN VOLUNTEER APPLICATION TEEN VOLUNTEER APPLICATION First Name Last Name Male/Female Date Home Phone Cell Phone Preferred Phone Address Email Want to receive our email newsletter? Y/N City State Zip Code Social Security # or provide

More information

Healthy Children Iniative

Healthy Children Iniative Healthy Children Iniative Introduction The Departments of Education, Culture and Employment and Health and Social Services are working together to achieve a vision where: Healthy children of healthy parents

More information

AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM

AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM RAILROAD BRIDGE WINGS NECK R.R. BRIDGE SANDWICH CURRENT TURNS JANUARY ---- 1230 0612 1848 Thursday 1 0442 1708 ---- 1200* 0554 1813 0033 1312* 0747 2023 0123 1406* ---- ---- ---- 2346 0042 1324 0706 1948

More information

Target Store Recruitment Application Form

Target Store Recruitment Application Form Store Use Only to be completed upon receipt of application from applicant Store Number: Is privacy statement signed? Yes Received By: Date Received: Has applicant retained Reference Page? Yes Target Store

More information

The Life Center Church Mentoring Program

The Life Center Church Mentoring Program The Life Center Church, Inc. 63 E. Kennedy Blvd. Eatonville, Florida 32751 Mentee Referral Form, Page 1 Youth Name: Parent/Guardian Phone Number Age: Grade: School: Requested by: Position: Phone Number:

More information

Annual Enrollment Application and Contract (For Preschool-age and older)

Annual Enrollment Application and Contract (For Preschool-age and older) Annual Enrollment Application and Contract (For Preschool-age and older) Child's Name: Date of Birth: Phone Number: City: State: Zip Code: Session (F)ull or (P)art Time Arrival Time Departure Time Rate

More information

REQUIREMENTS FOR VOLUNTEERS Please DO NOT send anything via fax, mail or

REQUIREMENTS FOR VOLUNTEERS Please DO NOT send anything via fax, mail or 1. Application (see next page) REQUIREMENTS FOR VOLUNTEERS Please DO NOT send anything via fax, mail or email Complete front and back. Please sign and date. 2. One Professional Letter of Reference (Typed)

More information

volunteer opportunities

volunteer opportunities volunteer opportunities Volunteering is a truly worthwhile experience. Organizations that utilize volunteers benefit by having added resources to sustain, expand or introduce new initiatives which generate

More information

Make a World of Difference at the Library Bonner Springs City Library

Make a World of Difference at the Library Bonner Springs City Library Make a World of Difference at the Library Volunteers must have completed 6 th grade. Please return by Friday, May 8th (All information must be completed in full and returned on time for consideration.)

More information

Bethalto Public Library District EMPLOYMENT PREVIEW

Bethalto Public Library District EMPLOYMENT PREVIEW EMPLOYMENT PREVIEW We are pleased that you are interested in employment with the Bethalto Public Library District. Please allow us to preview what you can expect while working for the Library. Public libraries

More information

DELEGATE APPLICATION June 16 June 19, 2014 Riverside Presbyterian Church 849 Park Street Jacksonville, FL 32204

DELEGATE APPLICATION June 16 June 19, 2014 Riverside Presbyterian Church 849 Park Street Jacksonville, FL 32204 Metrotown Institute DELEGATE APPLICATION June 16 June 19, 2014 Riverside Presbyterian Church 849 Park Street Jacksonville, FL 32204 What is Metrotown Institute? The OneJax Metrotown Institute is a gathering

More information

Your child s school nurse

Your child s school nurse Your child s school nurse An introduction for parents, guardians and carers What is this leaflet for? This leaflet explains about the school nurse service. Every school in Grampian has a named school nurse.

More information

What Is the Olweus Bullying Prevention Program?

What Is the Olweus Bullying Prevention Program? Dear Parent/Guardians, Your child s school will be using the Olweus Bullying Prevention Program. This research-based program reduces bullying in schools. It also helps to make school a safer, more positive

More information

COMPREHENSIVE HIGH SCHOOL TRANSITION SURVEY TRANSITION ASSESSMENT/INTERESTS, PREFERENCES, STRENGTHS & NEEDS. Full Name: Birthdate: / / Age:

COMPREHENSIVE HIGH SCHOOL TRANSITION SURVEY TRANSITION ASSESSMENT/INTERESTS, PREFERENCES, STRENGTHS & NEEDS. Full Name: Birthdate: / / Age: COMPREHENSIVE HIGH SCHOOL TRANSITION SURVEY TRANSITION ASSESSMENT/INTERESTS, PREFERENCES, STRENGTHS & NEEDS Full Name: Birthdate: / / Age: Address: Phone #: Cell #: Disability: Parent/Guardian Name: Work

More information

Dear Prospective Volunteer:

Dear Prospective Volunteer: Dear Prospective Volunteer: Thank you for your interest in volunteering at Robert Wood Johnson University Hospital Hamilton. We accept applications from college students for summer commitments, year round

More information

Volunteer Services 1950 Mountain View Ave Longmont, CO 80501 (303) 651-5205 Fax (303) 678-4851

Volunteer Services 1950 Mountain View Ave Longmont, CO 80501 (303) 651-5205 Fax (303) 678-4851 Volunteer Services 1950 Mountain View Ave Longmont, CO 80501 (303) 651-5205 Fax (303) 678-4851 Dear Prospective Junior Volunteer: Thank you for your interest in Longmont United Hospital s Junior Volunteer

More information

What is the Phoenix Transition Housing Program? What is the acceptance criteria? How do you apply to access the Phoenix Transition Housing Program?

What is the Phoenix Transition Housing Program? What is the acceptance criteria? How do you apply to access the Phoenix Transition Housing Program? What is the Phoenix Transition Housing Program? The Phoenix Transition Housing Program is a Provincial Homelessness Initiative developed in partnership with BC Housing that provides safe, structured housing

More information

LEARNER OUTCOME 1 W-7.13:

LEARNER OUTCOME 1 W-7.13: DECISION MAKING Lesson 1 GRADE 7 LEARNER OUTCOME 1 W-7.13: Examine the influences on personal decision making for responsible sexual behaviour. MATERIALS: 1. HANDOUT: My Personal Life Line 2. HANDOUT:

More information

EMPLOYMENT APPLICATION {PLEASE Print Clearly}

EMPLOYMENT APPLICATION {PLEASE Print Clearly} Date Received: Next Step: EMPLOYMENT APPLICATION {PLEASE Print Clearly} Date: Position applied for: Personal Information Legal Name: First Last Middle Initial Address: Street City State Zip code How long

More information

Volunteer Application Form

Volunteer Application Form Volunteer Application Form Please fill out each field clearly and mail to: Volunteer Services Department 3020 Children s Way m/c 5086 San Diego, California 92123 Office (858) 966-4021 Incomplete applications

More information

A Parent s Guide. Talking with your child about alcohol and other drugs. Helping our Communities to be Healthier

A Parent s Guide. Talking with your child about alcohol and other drugs. Helping our Communities to be Healthier A Parent s Guide Talking with your child about alcohol and other drugs Helping our Communities to be Healthier ISBN # 978-1-55471-238-0 CNB - 6569 1. Introduction Most of our children do not end up abusing

More information

CAO FL-3 PARENTING PLAN. The parents (Father) and (Mother) shall spend time with their children: Date of Birth

CAO FL-3 PARENTING PLAN. The parents (Father) and (Mother) shall spend time with their children: Date of Birth CAO FL-3 PARENTING PLAN The parents (Father) and (Mother) shall spend time with their children: Name as follows: Date of Birth 1. PARENT RESPONSIBILTIES When each child is in a parent s physical custody,

More information

This Order is effective beginning.

This Order is effective beginning. CASE NUMBER PARENTING TIME GUIDELINES FOR THE NON-RESIDENTIAL PARENT The Domestic Relations Court has developed these parenting time schedules for the purpose of assisting divorcing parents in formulating

More information

Pregnancy. U.S. Department of Health and Human Services. National Institutes of Health. In cooperation with

Pregnancy. U.S. Department of Health and Human Services. National Institutes of Health. In cooperation with Drinking and Your Pregnancy U.S. Department of Health and Human Services National Institutes of Health National Institute on Alcohol Abuse and Alcoholism In cooperation with The National Organization on

More information

My Life My Plan. Property of:

My Life My Plan. Property of: My Life This booklet is for teens. It will help you think about how the decisions you make today can help you live a healthy and happy life now and in the future. Property of: Now could be a great time

More information

Fixture List 2018 FIFA World Cup Preliminary Competition

Fixture List 2018 FIFA World Cup Preliminary Competition Fixture List 2018 FIFA World Cup Preliminary Competition MATCHDAY 1 4-6 September 2016 4 September Sunday 18:00 Group C 4 September Sunday 20:45 Group C 4 September Sunday 20:45 Group C 4 September Sunday

More information

Dear Teen Volunteer Applicant,

Dear Teen Volunteer Applicant, Dear Teen Volunteer Applicant, Thank you for considering a position with the Teen Volunteer Program at Methodist Jennie Edmundson Hospital. Since your application is very important to us, we would like

More information

University of Central Arkansas Counseling Center Student Health Center Suite 327 Conway, AR 72035 (501) 450-3138

University of Central Arkansas Counseling Center Student Health Center Suite 327 Conway, AR 72035 (501) 450-3138 Page1 University of Central Arkansas Counseling Center Student Health Center Suite 327 Conway, AR 72035 (501) 450-3138 UCA Counseling Center Client Information Eligibility: Counseling services of the Center

More information

JUNIOR VOLUNTEER APPLICATION PACKET

JUNIOR VOLUNTEER APPLICATION PACKET APPLICATION PACKET Thank you for your interest in the Junior Volunteer Program at Nazareth Hospital. There are a limited number of positions available for Junior Volunteers during the summer. Service will

More information

PERKINS CHILD CARE ASSISTANCE APPLICATION

PERKINS CHILD CARE ASSISTANCE APPLICATION Check ALL that apply: PERKINS CHILD CARE ASSISTANCE APPLICATION SEMESTER YEAR: 20_ SEMESTER YEAR: 20_ Fall Spring SI SII Fall Late Start Spring Late Start Spring Mini Please PRINT: Name: Address: ID #

More information

Grade 8 Lesson Peer Influence

Grade 8 Lesson Peer Influence Grade 8 Lesson Peer Influence Summary This lesson is one in a series of Grade 8 lessons. If you aren t able to teach all the lessons, try pairing this lesson with the Substance and Gambling Information,

More information

Applicant Information

Applicant Information Full Name: 700 Route 130 North, Suite 212, Cinnaminson, NJ 08077 856-470-9018 609-450-1719 fax 856-499-2971 Employment Application for A+ Senior Care **PLEASE PRINT CLEARLY AND ANSWER ALL QUESTIONS IN

More information

Sample Individual Treatment Plan (ITP) Individuals Involved in the development of the ITP Client/Agency/Title/Family Member/Other (specify)

Sample Individual Treatment Plan (ITP) Individuals Involved in the development of the ITP Client/Agency/Title/Family Member/Other (specify) Sample Individual Treatment Plan (ITP) Client Name: Tony Date of Plan 7-04 Client ID: 1234567 Individuals Involved in the development of the ITP Client/Agency/Title/Family Member/Other (specify) Tony Client

More information

FAMILY LAW AND YOUNG PEOPLE

FAMILY LAW AND YOUNG PEOPLE FAMILY MATTERS FAMILY LAW AND YOUNG PEOPLE IN SCOTLAND FAMILY LAW AND YOUNG PEOPLE IN SCOTLAND Scottish Ministers vision for children and young people 1 in Scotland is that they are safe, nurtured, achieving,

More information

Rose Bowl Aquatics Center Application for Employment

Rose Bowl Aquatics Center Application for Employment Rose Bowl Aquatics Center Application for Employment Applicants may be tested for illegal drugs PERSONAL INFORMATION Date Completed: Social Security Number: - - Present Last First Middle Maiden Number

More information

Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you!

Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you! Thank you for choosing The Center for Bone and Joint Health for your care. The providers and staff welcome you! To simplify the registration process during your first visit we ask that you take a moment

More information

NEW PATIENT REGISTRATION

NEW PATIENT REGISTRATION NEW PATIENT REGISTRATION PARK TUDOR It is required that ALL minors be accompanied by a parent or legal guardian at the initial visit. PATIENT NAME LAST: FIRST: MI: NICKNAME: DATE OF BIRTH: / / AGE: SSN:

More information

Teens in Foster Care and Their Babies

Teens in Foster Care and Their Babies Teens in Foster Care and Their Babies 2013 If you are a pregnant or parenting teenager in foster care, you may have some questions or concerns. Being a teen parent can be stressful, and the added demands

More information

eday Lessons Physical Education: High School PE I, PE II, and Advanced PE

eday Lessons Physical Education: High School PE I, PE II, and Advanced PE Physical Education: High School PE I, PE II, and Advanced PE Lesson #1: High School Physical Education E-Lessons, PE I, PE II, and Advanced PE. Standard 3 Participates regularly in physical activity. Grade

More information

LUTHERAN HEALTH NETWORK ADULT VOLUNTEER SERVICES APPLICATION

LUTHERAN HEALTH NETWORK ADULT VOLUNTEER SERVICES APPLICATION LUTHERAN HEALTH NETWORK ADULT VOLUNTEER SERVICES APPLICATION Adult - For Internal Use: Certifications: Community Service? Thank you for your interest in volunteering at Lutheran Hospital. Volunteers are

More information

Measuring in Centimetres

Measuring in Centimetres 1 Measuring in Centimetres Estimate and measure lengths in centimetres. You will need a centimetre ruler. 1. Use your hands and fingers to estimate the length of each object. Write your estimates. Then

More information

MISSION STATEMENT PHILOSOPHY

MISSION STATEMENT PHILOSOPHY MISSION STATEMENT The Cranston Public School District s mission of inclusion, through a partnership involving regular education, special education, and families is to set appropriate challenges and goals

More information

First Name Last Name. Street Address. City/State/Zip Code. Home Phone Cell Phone. Date of Birth Social Security # School Name Grade

First Name Last Name. Street Address. City/State/Zip Code. Home Phone Cell Phone. Date of Birth Social Security # School Name Grade Teen Summer Camp Volunteer Program Job Description Teen Summer Camp Volunteer Program Teen Camp Counselor Application Date First Name Last Name Street Address City/State/Zip Code Home Phone Cell Phone

More information

Depression. Information for service users and carers. RDaSH. Adult Mental Health Services

Depression. Information for service users and carers. RDaSH. Adult Mental Health Services Depression Information for service users and carers RDaSH Adult Mental Health Services Depression is a very common problem. It can affect anyone, regardless of your age, personality, culture, social or

More information

Community Care Services Division

Community Care Services Division Informing and supporting families who provide assistance and care for older adult relatives, partners or friends. Counseling Get assistance identifying strategies, options and resources for the care of

More information

CHILD CUSTODY QUESTIONNAIRE

CHILD CUSTODY QUESTIONNAIRE CHILD CUSTODY QUESTIONNAIRE About You Social Security Number: Please state your residence address for the last five (5) years: (Please include, City, State) Residence Current Employer Name: Please state

More information

VOLUNTEER APPLICATION

VOLUNTEER APPLICATION VOLUNTEER APPLICATION The information on this application will help us find the most satisfying and rewarding volunteer service for you. You may include any additional information by attaching it to the

More information

Junior Volunteer Application (Ages 14-18)

Junior Volunteer Application (Ages 14-18) Volunteer Name: Volunteer Age: Volunteer Grade: Junior Volunteer Application (Ages 14-18) Medical Center Alliance 3101 North Tarrant Parkway Fort Worth, TX 76177 Phone: 817-639-1000 Fax: 817-639-1727 If

More information

Teen Assessment Spirituality

Teen Assessment Spirituality Spirituality You have indicated that you need to pay more attention to the area of Spirituality. We recommend developing I may not know what I want to do yet with my life, but I know my life has meaning

More information

New York Marathon Train Start Date: May 6, 2013

New York Marathon Train Start Date: May 6, 2013 Start Date: Gun Times: Variable, around 1 FOCUS: Build Volume (Low Heart Rate) Form & Base Phase One Monday Tuesday Wednesday Thursday Friday Saturday Sunday Notes Pace = slower Pace = slower Pace = slower

More information

Ten Tips for Parents. To Help Their Children Avoid Teen Pregnancy

Ten Tips for Parents. To Help Their Children Avoid Teen Pregnancy Ten Tips for Parents To Help Their Children Avoid Teen Pregnancy Ten Tips for Parents To Help Their Children Avoid Teen Pregnancy The National Campaign to Prevent Teen Pregnancy has reviewed research

More information

Virginia Conference of The United Methodist Church Older Adult Ministry Council. Older Adult Survey Form

Virginia Conference of The United Methodist Church Older Adult Ministry Council. Older Adult Survey Form Virginia Conference of The United Methodist Church Older Adult Ministry Council Older Adult Survey Form We often hear people within the local church saying that their churches, districts, and the Conference

More information

How Care Management Can Help You. Disease Management Program. MISSOURI 2015 ISSUE ii

How Care Management Can Help You. Disease Management Program. MISSOURI 2015 ISSUE ii MISSOURI 2015 ISSUE ii How Care Management Can Help You Got a question or concern about your health? Care Management helps members with special needs. It pairs a member with a care manager. The care manager

More information

Target Store Recruitment Application Form

Target Store Recruitment Application Form Store Use only to be completed upon receipt of application from applicant Store Number: Is privacy statement signed? Received By: Date Received: Has applicant retained Reference Page? Target Store Recruitment

More information

Accident Investigation Protocol

Accident Investigation Protocol Accident Investigation Protocol This Protocol is inserted for example only. An accident investigation is usually completed by NELCO' Workers Compensation Section as a service to our Clients via telephone.

More information

Recreation & Community Services Camp Serendipity Summer Day Camp 2016

Recreation & Community Services Camp Serendipity Summer Day Camp 2016 Recreation & Community Services Camp Serendipity Summer Day Camp 2016 Camp Phone & Address Performing Arts Center (Youth Center) 800 Hobson Way (805) 385-8168 (Camp Site) (805) 890-6321 (Camp Site Cell)

More information

Family. CalWORKs. Opportunity. Making the Connection

Family. CalWORKs. Opportunity. Making the Connection Family CalWORKs Opportunity Making the Connection CalWORKs CalWORKs (California Work Opportunities and Responsibility to Kids) is a plan developed in response to the Federal TANF (Temporary Aid to Needy

More information

DO YOU EVER FEEL DEPRESSED?

DO YOU EVER FEEL DEPRESSED? DO YOU EVER FEEL DEPRESSED? WE ALL HAVE TO DEAL WITH DIFFERENT KINDS OF FEELINGS AND EMOTIONS SOMETIMES WE FEEL HAPPY AND EXCITED AT OTHER TIMES, WE LL FEEL SAD AND DOWN There are lots of things that might

More information

The 2016 San Francisco Police Foundation High School Student Stipend Internship

The 2016 San Francisco Police Foundation High School Student Stipend Internship The 2016 San Francisco Police Foundation High School Student Stipend Internship SFPD Youth and Community Engagement Unit 1245 3 rd Street, 5 th Floor San Francisco, CA 94158 Officer Raphael Rockwell Email:

More information

The Hope House 25 th Street Little Rock, AR 72204 501-351-5164***501-565-HOPE. Name DOB AGE SSN: DL# Current Address: Phone #: Sobriety Date:

The Hope House 25 th Street Little Rock, AR 72204 501-351-5164***501-565-HOPE. Name DOB AGE SSN: DL# Current Address: Phone #: Sobriety Date: The Hope House 25 th Street Little Rock, AR 72204 501-351-5164***501-565-HOPE Name DOB AGE SSN: DL# Current Address: Phone #: Sobriety Date: Employer name Phone #: Position Supervisor Emergency contact:

More information

Center for Family Development Child/Teen Intake Questionnaire

Center for Family Development Child/Teen Intake Questionnaire Center for Family Development Child/Teen Intake Questionnaire Parents-In order for me to be able to fully evaluate your child or teenager, please fill out the following intake form and questionnaires to

More information

Please be advised that monthly fees for the BEST Program are based on the state required 180 school days divided into 10 even monthly payments.

Please be advised that monthly fees for the BEST Program are based on the state required 180 school days divided into 10 even monthly payments. Brick Township Public Schools Brick Extended School Time Before and After School Care & Kindergarten Wrap Around 224 Chambers Bridge Rd - Brick, NJ 08723-732-262-2590 ext. 1531 BEST Program Families: Thank

More information

JESUS CARES MINISTRIES INTERVIEW SHEET TODAY'S DATE. NAME PHONE AGE first middle last ADDRESS CITY STATE ZIP HEIGHT WEIGHT HAIR COLOR EYE COLOR RACE

JESUS CARES MINISTRIES INTERVIEW SHEET TODAY'S DATE. NAME PHONE AGE first middle last ADDRESS CITY STATE ZIP HEIGHT WEIGHT HAIR COLOR EYE COLOR RACE JESUS CARES MINISTRIES INTERVIEW SHEET TODAY'S DATE NAME PHONE AGE first middle last ADDRESS CITY STATE ZIP HEIGHT WEIGHT HAIR COLOR EYE COLOR RACE BIRTHDAY DATE MARITAL STATUS SOC SECURITY # DO YOU HAVE

More information

January. Success Principles SUNDAY MONDAY TUESDAY WEDNESDAY. How to Get From Where You Are to Where You Want to Be

January. Success Principles SUNDAY MONDAY TUESDAY WEDNESDAY. How to Get From Where You Are to Where You Want to Be g he Success Principles How to Get From Where You Are to Where You Want to Be January You must take personal responsibility. You cannot change the circumstances, the seasons, or the wind, but you can change

More information

Cruise Line Agencies of Alaska. Cruise Ship Calendar for 2016 FOR PORT(S) = KTN AND SHIP(S) = ALL AND VOYAGES = ALL

Cruise Line Agencies of Alaska. Cruise Ship Calendar for 2016 FOR PORT(S) = KTN AND SHIP(S) = ALL AND VOYAGES = ALL Cruise Line Agencies of Alaska Cruise Ship Calendar for 2016 FOR PORT(S) = KTN AND SHIP(S) = ALL AND VOYAGES = ALL Page 1 of 5 Sunday, May 1 07:0-18:0 Monday, May 2 Tuesday, May 3 Wednesday, May 4 Thursday,

More information

PARENTING PLAN. This Parenting Plan Agreement is entered into by and between Petitioner * * *

PARENTING PLAN. This Parenting Plan Agreement is entered into by and between Petitioner * * * PARENTING PLAN OPTION 1: This Parenting Plan Agreement is entered into by and between Petitioner * * * (Father/Mother) and Respondent *** (Father/Mother). The parties have [no.] child/ren to which this

More information

Shop with a Buccaneer 2014 Mentor Application

Shop with a Buccaneer 2014 Mentor Application Shop with a Buccaneer 2014 Mentor Application * * * * * * * * * * * * * * * It s hard to believe, but the Holidays are already upon us - a time for family and relaxation, but most of all, generosity. Every

More information

Page 1. Boone s Creek Baptist Association Serving, Encouraging, and Supporting

Page 1. Boone s Creek Baptist Association Serving, Encouraging, and Supporting Page 1 Boone s Creek Baptist Association Serving, Encouraging, and Supporting Post Office Box 537, Winchester, KY 40392 E-mail : boonescreekbapti@bellsouth.net Website:www.boonescreekbaptistassoc.com Summer

More information

APPLICATION FOR AT WILL EMPLOYMENT

APPLICATION FOR AT WILL EMPLOYMENT APPLICATION FOR AT WILL EMPLOYMENT PLEASE PRINT ALL INFORMATION Position Applied for: Date of Application: How Did You Learn About Us? Advertisement Friend Walk In Website Relative Other Last Name First

More information

Summer Internship Program 2015

Summer Internship Program 2015 Summer Internship Program 2015 Application Process: 1. Read & Submit this application and résumé to our Welcome Center / FH Offices or email to Brian@thefreedomhouse.org. Application Deadline is Sunday

More information

Rethink 2008 www.rethink.org. the mental health act. essential information for parents and carers

Rethink 2008 www.rethink.org. the mental health act. essential information for parents and carers Rethink 2008 www.rethink.org the mental health act essential information for parents and carers 1 About Rethink Rethink, the leading national mental health membership charity, works to help everyone affected

More information

Windsor Regional Hospital Paediatrics

Windsor Regional Hospital Paediatrics Windsor Regional Hospital Paediatrics Volunteer Orientation Manual Child Life Services 519-254-5577 x 53408 Revised: July 2006 Windsor Regional Hospital 1 Child Life Services Volunteer Manual Welcome Child

More information

Please check the course(s) you are registering for.

Please check the course(s) you are registering for. Camp Immanuel Where Faith and Fun Come Together 18 Clapboard Ridge Road Danbury, CT 06811 www.immanueldanbury.org camp.immanuel@immanueldanbury.org 203-748-7823 Thank you for your interest in Camp Immanuel.

More information

Patient & Practice Charter

Patient & Practice Charter PEARTREE MEDICAL CENTRE 159 Peartree Road Normanton Derby DE23 8NQ Patient & Practice Charter 2013 1 Telephone: 01332 360692 Fax: 01332 368181 Out of Hours: 111 Peartree Medical Centre Staff Doctors Dr

More information

COUPLES THERAPY INTAKE FORM Please complete this form individually

COUPLES THERAPY INTAKE FORM Please complete this form individually COUPLES THERAPY INTAKE FORM Please complete this form individually Date file opened: Chart #: First name: Last name: Age: Birth day: Month: Year: Ethnicity: Religion: Marital Status: Sex/gender: Number

More information

Cruise Line Agencies of Alaska. Cruise Ship Calendar for 2016 FOR PORT(S) = KTN AND SHIP(S) = ALL AND VOYAGES = ALL

Cruise Line Agencies of Alaska. Cruise Ship Calendar for 2016 FOR PORT(S) = KTN AND SHIP(S) = ALL AND VOYAGES = ALL Cruise Line Agencies of Alaska Cruise Ship Calendar for 06 FOR PORT(S) = KTN AND SHIP(S) = ALL AND VOYAGES = ALL 6: Friday, April 5, 06 Cruise Line Agencies of Alaska, Cruise Ship Calendar for 06 Page

More information

Sample Job Description Questions

Sample Job Description Questions Sample Job Description Questions Here is a list of questions that could be used to develop a job description: Brief summary of work What are the qualifications for this job? (Examples: dependability, able

More information

Wartburg College Orientation Team New Staff Application Packet

Wartburg College Orientation Team New Staff Application Packet Wartburg College Orientation Team New Staff Application Packet 2016-2017 Applications Due: Noon on Friday, January 15, 2016 Wartburg College Office of Campus Programming Phone: (319) 352-8486 Email: studentorgs@wartburg.edu

More information

Basic: Communities, Week 4 Bank & Library

Basic: Communities, Week 4 Bank & Library Basic: Communities, Week 4 Bank & Library Unit objective: Students will be able to fill out a deposit slip, practice a dialogue at the bank, fill out a library application, practice a dialogue at the library

More information

PROJECT EXCEL MENTORING PROGRAM Creating Vision Through Mentoring / What They See is What They Will Be

PROJECT EXCEL MENTORING PROGRAM Creating Vision Through Mentoring / What They See is What They Will Be Personal Information Mentee Application (To Be Completed by the Parent/Guardian) Youth s Name: Date: Parent/Guardian Name: Relationship to Youth: Mother Father other, specify: Street Address: City: State:

More information

Teen Success Agreement

Teen Success Agreement Teen Success Agreement A youth-developed written agreement for older youth, caregivers, and social workers to provide older youth age-appropriate activities and opportunities TABLE OF CONTENTS INTRODUCTION

More information

Register To Volunteer with Weave

Register To Volunteer with Weave Register To Volunteer with Weave Do you want to become a volunteer? Complete the below volunteer registration form and we will email you to arrange an interview. * Please complete all of the fields marked

More information

Statutory Rape: What You Should Know

Statutory Rape: What You Should Know Statutory Rape: What You Should Know 2013 Why Do You Need To Read This? Many teens are concerned about the laws regarding something commonly called statutory rape. This brochure will explain what statutory

More information

STATEMENT OF PURPOSE

STATEMENT OF PURPOSE DRINKING PROBLEM? FOUNDATION HOUSE MEN S SOBER LIVING HOUSE FOR FUN AND FOR FREE NOT FOR PROFIT STATEMENT OF PURPOSE To provide an environment of sober and clean living by utilizing the spiritual principles

More information

MENDING HEARTS HALF-WAY HOUSE RULES REVISED 4-13

MENDING HEARTS HALF-WAY HOUSE RULES REVISED 4-13 MENDING HEARTS HALF-WAY HOUSE RULES REVISED 4-13 Restoring Women, Reclaiming Lives In order to help you become more comfortable with your surroundings, we have listed the following rules and regulations

More information

Big Spring Independent School District 708 11 th Place Big Spring, Texas 79720

Big Spring Independent School District 708 11 th Place Big Spring, Texas 79720 OFFICE USE ONLY Date Rec d: Campus: Student ID: Big Spring Independent School District 708 11 th Place Big Spring, Texas 79720 Physician s Verification of Need for Homebound Services Student s Legal Name:

More information