This form is used for Women Centre of Jamaica Foundation prospective students. Introduction Info Pregnancy Information Extended Information Personal Info Which centre will you be registered with Kingston Centre Savanna-La_mar Centre Montego Bay Centre Spanish Town Centre Port Antonio Centre Mandeville Centre Surname First Name Middle Initial Email Date of Birth Birth Certificate Entry Number Telephone Number Address(es) and Directions Type of Accomodation How long have you lived at your present address? 0 - 3 Years 3 - 5 Years 5 - 7 Years 7+ Years Who do you currently reside with? Economic Status Lower Class Middle Class Upper Class Please specify any family problems that you may have. Hobbies Church Affiliation / Denomination Referred By: Age of mother's first pregnancy? 13 years old or under 14 years old 15 years old 16 years old 17 years old 18 years old or older Emergency Contact Information Emergency Contact Name Relationship Mother Father Brother Sister Relative Other Occupation Address Telephone Numbers Mother's Contact Information Surname, First Name Address Telephone Number(s) Employment Information Fathers's Contact Information Surname, First Name Address Telephone Number(s) Employment Information Guardian Contact Information Surname, First Name Address Telephone Number(s) Employment Information Child's Father Information Surname, First Name Address Telephone Number(s) Employment Information Friend(s) Information Please provide the following information: Name of your friend(s) and their occupation. Pregnancy Information L.M.P When is your due date? The pregnancy was: planned Unplanned If the pregnancy was planned, please explain the family planning process. Have you made an appointment at an antenatal clinic? Yes No Please state which clinic: Clinic Appointment Date Are you suffering from any particular health problems? Yes No If yes, please explain: What do you plan to do with your baby? Keep For Adoption Other Who will assist you with the baby when you return to school? Parent Relative Helper Friend Baby\\\'s Father Daycare Other In what way will this person help you with the baby? Contraceptive Method What contraceptive method do you use? Condoms Birth Control Pills What contraceptive method do you use? What contraceptive method do you use? Depo Provera Other If other, state the method Why do you prefer this method? School Information Name of school you last attended Address Telephone Number Date you last attended Grade Reached Favourite Teacher's Name Favorite Subject Baby Information Date of Delivery/Birth Place of Delivery/Birth Type of Delivery / Birth Type of Delivery / Birth C-Section Assisted vacuum extraction Unsure Other The delivery was The delivery was Full term Premature Not born yet Other Baby's birth weight Baby's Sex Male Female Unsure Baby's Surname, First Name Has the baby been registered? Yes No State all problems related to the delivery. Other Information Are you a PATH beneficiary? Yes No How did you learn about the Women's Centre of Jamaica Foundation? Have you ever experienced Physical abuse Sexual abuse Emotional abuse Mental abuse None Other If abused, by whom were you abused by? Have you ever been tested for HIV/AIDS? Yes No When were you last tested for HIV/AIDS? SHOW SUMMARY Some required Fields are emptyPlease check the highlighted fields. Submit Previous Step Next Step
