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 InformationName* First Last Email* Your Date of Birth* Age*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Alternate PhoneCheck if it is okay to leave a message on your phone(s): 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:MarriedSeparatedDivorcedSingleLiving TogetherWidowedLiving SituationAloneBoyfriendHusbandRoommate(s)Parent(s)FamilyOtherPlease explain Other Living SituationSupport System*Describe your support networkWill a support person be attending classes with you?*NoYesWho will be attending classes with you?ConcernsWhat are your primary concerns regarding pregnancy and parenting?Pregnancy InformationAre you pregnant at this time?*YesNoWhen is your due date? Do you have other children?*NoYesAvailabilityAppointments 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 GoalsProgram 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. AgreementI 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.