BIRTH AND PARENT COMPANION PROGRAM APPLICATION

Date(M/D/Y)

(M/D/Y)

Program

Birth

Parent

Both

PROGRAM (Please note you must be a parent to be a Parent Companion)

First Name *

Last Name *

Address

Postal Code

Home Phone #

Cell #

Other #

Email Address

Date of Birth

(M/D/Y)

English Language

Basic

Conversational

Fluent

French Language

Basic

Conversational

Fluent

Other Languages

What is your main method of transportation?

Emergency Contact *

Phone Number *

How is your emergency contact related to you? *

Flexibility

Due to the on-call nature and unpredictability of birth, Birth Companion volunteers are at times required to attend births at all times of the day/night. Should you become a BC, it is important to discuss this possibility with your employer and family.

Employment Notes

Family Notes

Captcha

How did you find out about the Birth and Parent Companion Program?

What motivates you to want to become a Companion?

What personal attributes/qualities do you possess that would make you a good Companion?

What life experiences, personal and/or professional, have you had that would be an asset to your role as a Companion? Please include any relevant education or training.

Birth Companion's match lengths can vary from 6 weeks to 1 year. Can you commit to supporting a match for this length of time?

As a Birth Companion, are you able to commit to a minimum of one professional development workshop per year?

Parent Companions are asked to volunteer at least once a week for the first month, then once every two weeks for the duration of the match. Can you commit to supporting a match for this length of time?

Do you have any environmental, food or pet allergies and/or objections to pets in the home?

Are there any medical conditions or general concerns that might impact your ability to perform your duties as outlined in the Position Description (i.e. environmental allergies, mobility issues, general concerns etc.)?

“Please provide 3 professional references only (not friends/family) who can comment on your character as well as your work ethic and suitability as a Birth or Parent Companion. Please include all requested contact info.” *

PROFESSIONAL REFERENCE #1 First Name *

Last Name *

Position

Agency

Home #

Cell # *

Work #

Other#

Email

Please explain how you know this person and why you have chosen them as a reference.

PROFESSIONAL REFERENCE #2 First Name *

Last Name *

Position

Agency

Home #

Cell # *

Work #

Other #

Email

Please explain how you know this person and why you have chosen them as a reference.

PROFESSIONAL REFERENCE #3 First Name *

Last Name *

Position

Agency

Home #

Cell # *

Work #

Other #

Email

Please explain how you know this person and why you have chosen them as a reference.

I certify that all of the information provided in this application is true. *

Please put your name and date (M/D/Y)

Pregnancy

Pregnancy

Infant

Infant

Toddler

Toddler

Preschool

Preschool

Kinder

Kinder

School Age

School Age

Parenting

Parenting