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Earn While You Learn Application Form

In this program you will have the opportunity to learn about pregnancy and parenting skills. Parents participating in EWYL will meet once a week for one hour with a peer-mentor for lessons. Lessons are taught through videos and worksheets. Through participation ‘Baby Bucks’ (vouchers) can be earned to use in the Baby Shop. Items include new and gently used maternity clothes, baby clothes, diapers, wipes, blankets and more. The prices of items are posted in the Shop and can be redeemed with ‘Baby Bucks’ upon availability. The WCPC reserves the right for decisions of availability and pricing for all of our resources. The EWYL program is designed to meet the needs of parents who may feel the need for extra support in preparing for parenthood.
Contact Information
Name*
First Last
Email*
Your Date of Birth*
MM slash DD slash YYYY
Age*
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Alternate Phone
Check if it is okay to leave a message on your phone(s):
- Yes, on my primary phone
- Yes, on my alternate phone
Check if it is okay to text you:
- Yes, on my primary phone
- Yes, on my alternate phone
Help us get to know you better so we can best serve your needs...
Marital Satus:
- Married
- Separated
- Divorced
- Single
- Living Together
- Widowed
Living Situation
- Alone
- Boyfriend
- Husband
- Roommate(s)
- Parent(s)
- Family
- Other
Please explain Other Living Situation
Support System*
Describe your support network
Will a support person be attending classes with you?*
- No
- Yes
Who will be attending classes with you?
Concerns
What are your primary concerns regarding pregnancy and parenting?
Pregnancy Information
Are you pregnant at this time?*
- Yes
- No
When is your due date?
MM slash DD slash YYYY
Do you have other children?*
- No
- Yes
Availability
Appointments are for one hour per week. It is our desire to work to the greatest ability to accommodate all client schedules. However, there are some circumstances in which we may not be able to accommodate all requests.
Note: The more flexible you are in your schedule, the sooner we will be able to start you in the Earn While You Learn program.
Availability*
- Mornings - Monday
- Mornings - Tuesday
- Mornings - Wednesday
- Mornings - Thursday
- Mornings - Friday
- Afternoons - Monday
- Afternoons - Tuesday
- Afternoons - Wednesday
- Afternoons - Thursday
- Afternoons - Friday
Please check all days and times that you are available.
Program Goals
Program Goals*
Please tell us what you hope to gain through participation in the Earn While You Learn program. Please also note specific goals you desire to achieve and any special topics you would like to learn about in regards to becoming the best parent you can be.
Agreement
I agree that I will be solely responsible for inspecting and determining the fitness and safety of any material items I receive in connection with the Earn While You Learn program. I agree to hold harmless the WCPC and/or any of its employees and agents with respect to any and all claims of whatever nature arising out of my participation in the Earn While You Learn program and/or my receipt of any items in connection with such program. I understand that at any time my participation in the Earn While You Learn program may be revoked as deemed appropriate by clinic staff. I have read and understood the above information.
The Whatcom County Pregnancy Clinic (WCPC) is a faith-based, nonprofit organization. All of our services are free to the client regardless of age, sex, race, income, nationality, religion, disability, marital status, or other arbitrary circumstances. We offer pregnancy tests with ultrasound when medically indicated, educational information, resource information, and access to the Baby and Me Shoppe through the Earn While You Learn program.
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