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Bundle of Support - Registration Form

  1. Copy of Postpartum Support Group
  2. REGISTRATION FORM
    INSTRUCTIONS: Please provide your information in the fields below to register for our support group. This should be completed by the individual who is planning to attend the group. Please ensure that you include a response for all fields with an asterisk (*).
  3. CONTACT INFORMATION
  4. Please provide the best phone number that you can be reached at
  5. We will be sending an email with the instructions to join the virtual support group as well as different resources throughout our time together.
  6. SCHEDULING AVAILABILITY
    INFORMATION: We will need to schedule an over-the-phone conversation with you in order to complete the intake process for our support group. We will be asking a series of questions, which should take anywhere from 15 minutes to 30 minutes in length.
  7. Please select the time(s) that you would be available for a phone call*
    Morning (9:00am - 11:30am) Afternoon (12:00pm - 4:30pm) Evening (4:30pm - 8:00pm)
  8. Is there a specific time during the day that you would like us to call you? Please list the date and time in the field below (ex. Monday, May 3rd at 4:30pm)
  9. FAMILY DEMOGRAPHICS
    WHY DO WE ASK FOR THIS INFORMATION? The demographic information collected in this section is used for reporting purposes only as required by our funder. Any question with an asterisk (*) is mandatory to complete, but those without can be skipped.
  10. Were you born in Canada?*
  11. If you were born in Canada, are you:
  12. If you were NOT born in Canada, have you lived here for less than 3 years?
  13. Please tell us how many children that you care for.
  14. Were your children:*
  15. If born in Canada are your children or youth
  16. If not born in Canada, have any been here less than 3 years?
  17. How did you learn about this workshop?*
  18. E.g. Synergy, FCSS, Trellis, Healthy Families
  19. Thank you for taking the time to complete this form. We look forward to connecting with you!
  20. Freedom of Information & Privacy (FOIP)
    Your personal information is being collected for activities related to the Parent & Caregiver Support Services (PCSS) program, workshop, seminar, and/or group activity and as such is deemed to be an activity of the City of Chestermere. The personal information is collected under the authority of Section 33(1)c of the Freedom of Information and Protection of Privacy Act, and will be used only for the purpose identified. If you have any questions or concerns about the collection or use of information you may contact the FOIP Coordinator at City Hall, 105 Marina Road, Chestermere, AB T1X 1V7, or call (403) 207-7050.
  21. PCSS Icon
  22. Trellis
  23. FRN color
  24. Leave This Blank:

  25. This field is not part of the form submission.