Waitlist- Postnatal Services / Baby & Me

Title *

Today's Date: *

Full Name (First and Last): *

Email Address: *

Phone Number: *

Which of the following program(s) are you interested in joining the waitlist for? *

Baby & Me Program TUESDAYS, 10:45am-12:45pm | OLIVET CHURCH, 613 QUEENS AVENUE, NEW WESTMINS

Baby & Me Program THURSDAYS, 12:45pm-3pm | EDMONDS RESOURCE CENTRE, ROOM 104, 7355 CANADA WAY, BURNABY

Please note this waitlist is for postnatal clients only and for those with infants under 6 months of age. If you are looking for prenatal services, please join our other waitlist.

Did you attend our BFL's prenatal program? *

Do you require child care for your other children while attending the program? *

Free child care available for children 18 months to 10 years with pre-registration. CHILDREN MUST BE OVER 18 MONTHS AND UNDER AGE OF 10 TO RECEIVE CARE.

If you require child care services, how many children do you need care for while you attend the program?

CHILREN MUST BE BETWEEN 18 MONTHS AND 10 YEARS OF AGE

How old are the children you require care for?

CHILDREN MUST BE BETWEEN 18 MONTHS AND 10 YEARS OF AGE

Please indicate how you were referred to the program? *

Please indicate where you currently live? *

All clients must live in Burnaby or New Westminster to participate in our programs at this time. Please visit https://www.bcapop.ca/ for other POPs programs in your area.

Please indicate your current age range. *

Date of Birth: *

Baby's Age: *

Please note our Baby & Me program is a support group for mothers experiencing emotional, social, financial and health challenges with infants 0-6 months. For programs for baby's older than 6 months, please email bfl_info@burnabyfamilylife.org.

Was this your first pregnancy? *

Please indicate why you are interested in attending this program. *

Please indicate which of the following issues/ barriers you may face. *

What are some of the resources you hope to access in the program? *

Estimated Annual Income: *

Anything else you want to tell us?

The below are for BFL Admin only to complete.

ADMIN ONLY: Exit Waitlist

ADMIN ONLY: Reason for Exit

ADMIN ONLY: Notes

ADMIN ONLY: Date of Exit

ADMIN ONLY: Move to Intake *

NOT YET CONFIRMED

Outreach Services

Group Services- Burnaby

Group Services- New West

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