Membership Application – International Life Services

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Pregnant?

Home
About Us
Scholl Institute
Centers
Speakers Bureau
Catalog
Blog
How to Help
- Prayer
- Donate
- Volunteer
Contact Us
Pregnant?

Fill out the online Membership Application below or Download and print the application and return to:
International Life Services
2606 ½ West 8th St.
Los Angeles, CA 90057.

Questions? Call 213-382-2156 or E-mail us at lifeservices@juno.com.

Membership Application

GENERAL CENTER INFORMATION

Date Center Opened

Proposed Date To Open

Center Name

Director Name

Mailing Address

City

State

Zip

Physical Address

City

State

Zip

Phone

Fax

Email(s)

Website(s)

Current Affiliations, Associations, Memberships

CENTER OPERATIONAL INFORMATION

Days/Hours Center is Open To Clients

AVERAGE MONTHLY CENTER CLIENT BREAKDOWN

Number of Clients Seen By Appointment

Number of “Drop-Ins”

Number of Telephone Calls

ADMINISTERING PREGNANCY TEST?

Do you offer pregnancy test?

What procedure is used for giving pregnancy test?

Self-Administered by clients

Administered by staff

Other (please explain below)

Other Procedure Explanation

Who gives the test results to the client?

Approximately how many tests were given in the last calendar year?

WHAT OTHER SERVICES DO YOU PROVIDE CLIENTS

Other Services Offered

Volunteering

Clothing

Furniture

STD testing

Other

List Other Services

VOLUNTEERING STAFF

Number of Center Volunteers

Briefly explain what training your center provides to volunteers.

Briefly explain what on-going, in-service training your center provides to volunteers.

What methods of evaluating and monitoring volunteering staff do you use?

OFFICE ADMINISTRATION STAFF

Number of Office Administration Staff

List different office positions.

HOTLINE SERVICES

Do you have a hotline?

How many hotlines volunteers do you have?

What training do your hotline volunteers receive?

What methods of evaluating and monitoring hotline volunteers do you use?

If you use another hotline service please list that information here.

CENTER INSURANCE

Does your center have insurance coverage?

List type of insurance you have.

General Liability

Professional Liability

Other

Name of provider

LEGAL INFORMATION

Legal Name of Center

Is your center a legally recognized non-profit entity under the laws of your state?

Date of Incorporation

Has your center received a 501(c)(3) tax exempt status with the IRS?

Pending, date of application to the IRS?

Are you a licensed clinic?

Does your center participate in or promote any illegal activities?

Has your center had any legal action/cases made against it?

If yes please explain.

Name

Title

Today's Date

If you are human, leave this field blank.

International Life Services
2606 1/2 W. 8th St., Los Angeles, CA 90057
213-382-2156
lifeservices@juno.com

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