Receipt # / Membership #
Alberta Home Visitation Network Association
9321 Jasper Avenue
Edmonton, AB T5H 3T7
Phone: 780 429-4787 Fax: 780 429-4784
Email:
Website: www.ahvna.org
Membership Application/Renewal –2012 (April 1 to March 31)
( Completion of all applicable sections required for membership )
Name of Program or Service:
Name of Agency / Organization:
Phone: Fax: Website:
Mailing Address:
City Prov Postal Code
Street Address (if different from above):
Contact Name:
Phone: Fax: Email:
Alternative Contact:
Phone: Fax: Email:
My organization is: / Renewing an existing membershipApplying for new membership
Type of Membership (if applicable):
Individual - a person not representing any program or organization
Organization - an incorporated not-for-profit entity/agency
Business - a for-profit entity e.g. small business, corporation
Government - e.g. Alberta Child and Youth Services, Alberta Health Services, Education
What committees, subcommittees, or working groups would you or your organization be interested in participating with?
May we include your organization’s contact information:
On a contact list provided to other AHVNA members? Yes No
On the above contact list and AHVNA’s website? Yes No
Membership Fee - $100.00 per yearAll cheques and money orders should be made payable to:
Alberta Home Visitation Network Association
Please mail application and cheque to address above.
Membership Benefits
¯an active exchange of home visitation experiences, knowledge and skills
¯training events at reduced cost
¯agency contact information on the website
¯one vote per membership
¯access to “members only” section on the website
Funding Information:
1. CFSA
2. Child and Youth
3. PHAC
4. FCSS
5. Alberta Health Services
6. Alberta Education
7. FNIHB
8. United Way
9. Donation
10. Fundraising
11. Other
(please specify) Total 100%
B. Partners (significant in-kind) Description
(e.g. office space)
Alberta Health Services
Other:
(please specify)
2. Alberta Children and Youth Services or CFSA / If your agency is contracted with Alberta Children and Youth Services or CFSA, what are your funding code(s)? Check all that apply.
356, 358 (ECD) 147, 360 (FASD) 355 (Home Visitation)
Others (specify both codes and descriptions):
Child and Family Service Regions:
1 2 3 4 5 6 7 8 9 10
Program Staffing:
Current Staffing: / Full-time Part-timeFTE’s * staff staff
Home Visitors …filled by… …and…
Supervisors/Leaders
Admin. Support
Manager/Exec.Dir.
Others (describe below)
* FTE = Full Time Equivalent
Description of Program/Service:
Complete this section if your program provides direct service to families.
1. Start date of program or service:2. Service area (i.e., what communities do you serve)?
3. Model(s) used
(check all that apply) / Great Kids Inc Healthy Families America
Invest in Kids Parents as Teachers
Other (please specify and describe below)
Description of other models:
4. Nature of program participation: / Voluntary Mandatory Both
(e.g., if families are referred to your program under a Child Protection Order or Support Agreement, or through the Courts, nature of participation would be Mandatory.)
5. Primary referral sources to the program (check all that apply) / Advertising CFSA Community Agency
Early Intervention Services Friend
Alberta Health Services Self referral
Other (please specify) ______
6a. When can families become involved in your program/ service (check all that apply) / Anytime during pregnancy Third trimester
Baby under 3 months old Up to 3 years after birth
Only with first baby Up to Age 5
Up to Age 6 No restrictions / Anytime
Other (please specify) ______
6b. How long may families stay involved? (check all that apply) / Up to child’s 3th birthday Up to child’s 5th birthday
Up to child’s 6th birthday As long as required
Other (please specify) ______
7. Standardized Screening Tools in use (check all that apply) / Brigance Early Childhood Screen
Calgary Postpartum Screening Tool
Healthy Families America Screen
Parents as Teachers Referral Checklist Parkyn Screen
Other (please specify and describe below)
Brief description of other screening process:
8. Standardized Assessment Tools in use (check all that apply) / Carey CDI Denver
DISC DPS Healthy Babies Healthy Children
Kempe Family Stress Test
Parent Development Questionnaire
Perceived Stress Scale
Other (please specify) ______
9. Ongoing Support Measurement Tools (check all that apply) / ASQ ASQ-SE Being a Parent CES-D
Edinburgh (Post Partum) Family Assessment Device (FAD)
Life Stress Scale Literacy MSSI
Nippissing Ounce Scale Parent Poll 1 & 2
Parent Survey – Home Literacy
Social Support Index
Other (please specify) ______
10. Do you currently rely on specific curriculum/resources when working with families? If so, which one(s)? / Great Kids
Health for Two books
Healthy Babies – Healthy Families, San Angelo Curriculum
Invest in Kids
Invest in Kids Activity Resource Guide for home visitors
Nobody’s Perfect
Parents as Teachers
Partners for a Healthy Baby (home visiting curriculum for families)
PIPE
Other (please specify and describe below)
Description of other curriculum:
11. What outcomes do you measure? / Child Development
Positive Parenting Skills
Increasing Protective Factors and Decreasing Risk Factors
Connections to Community
Other (please specify) ______
12. Do you have specific monitoring / evaluation / outcomes in place? If so, please describe. / No, or None at this time
Yes – check all that apply:
Alberta Child and Youth Services Pre-Post Survey
Canadian Outcomes Institute – HOMES (aggregate reports)
Family Service Plan / Goal Planning and Review
Parent Interviews
Parent Survey
Peer supervision
Other (please specify) ______
13. How do you primarily gather and track the majority of the information needed for various reports? (check all that apply) / Manual / Paper counting
Microsoft Access Database
Spreadsheets (i.e. Microsoft Excel)
Other (please specify database systems)
______
Any other information / comments you wish to provide?
If you have any questions about this survey or would like further information on AHVNA, please contact:
Lavonne Roloff Phone: (780) 429-4787
AHVNA Provincial Director Fax: (780) 429-4784
9321 Jasper Ave Email:
Edmonton, AB, T5H 3T7
(Rev. Jan 31, 2012) Page 1 of 4