(is section to be completed by the Knights of Columbus Council)
Sponsoring Knights of Columbus Unit: _____________________________________ Number: _____________
Contact Name: _______________________ Email: _____________________ Telephone:____________________
Pregnancy Center: _____________________________City:_______________ State/Province: ____________
Arch/diocese where center is located: ______________________________________________________________
(is Section to be completed by the Arch/diocesan Culture of Life Director)
e Knights of Columbus Council noted above is exploring the option of raising funds to provide (circle one):
1 - an ultrasound machine; or, 2 - an ultrasound machine and a vehicle (mobile unit) (i.e. – Bus, RV, Truck, Van, etc.),
to the pregnancy center indicated. To assist the Knights of Columbus in qualifying the pregnancy center for participation
in the Ultrasound Program, based on the experience and knowledge you have of this pregnancy center, please respond to
each statement below, or indicate that you do not have enough information on which to make a judgment.
1. e pregnancy center has the staffing, nances and other resources to justify and support the purchase and continued
operation of an ultrasound machine/mobile unit. is major expenditure and the ongoing costs and staffing
commitments are justied by the pregnancy centers location, client load, and hours of operation.
Yes ____ No _____ Do not know _____
2. e pregnancy center’s practices, policies and history regarding abortion, abortifacients, birth control and other
associated practices appear to be consistent with Catholic moral and ethical principles.
Yes ____ No _____ Do not know _____
3. Experience shows the pregnancy center is welcoming of Catholics as employees, volunteers and clients and is respectful
of the beliefs and faith practices of those Catholics. e pregnancy center has no official policies, practices, or office
climate that discriminates against Catholics, or that would encourage Catholic employees, volunteers or clients to
leave their Catholic faith.
Yes ____ No _____ Do not know _____
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4. If the pregnancy center has a Statement of Faith (SOF) that (indicate those affected) _____ employees, _____
volunteers, or _____ clients are asked to sign or assent to in their participation, presence, or in order to provide or
receive services at the pregnancy center, it has been evaluated in light of the policies of the arch/diocese Culture of
Life Office and the bishop.
______ e pregnancy center does not have a SOF.
______ e pregnancy center has a SOF (copy provided to the diocese) that is: consistent/inconsistent with
Roman Catholic teaching (select one): Consistent Inconsistent
Under discussion: Yes _____ No _____
5. Additional comments:
I recommend this pregnancy center for participation in the Ultrasound Program. Yes ______ No ______
______ I do not have enough information concerning this pregnancy center to make a judgment.
Print name: ___________________ Signature: _____________________Title: ______________ Date: _______
arch/diocese: ___________________________________ Telephone #:__________________________________
Address: ____________________________________________________________________________________
Email a copy of this document to: fraternalmission@kofc.org
(Councils should also retain a copy of this completed form for their les)
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