Pritzker P3 Action Team Support Request
Name
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Organization that you represent
*
Email Address
*
Phone Number
*
City and county where meeting will be held
*
Date of the meeting
*
mm/dd/yyyy
Who will be participating
Who will be participating
Check all that apply
Parents
Service Providers
Community Leaders
Philanthropic Organizations
Other
Estimated number of participants
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Estimated number of parents who will participate
*
Anticipated time focused on an Action Team Topic
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Action Team Topic(s) that this meeting will support
Action Team Topic(s) that this meeting will support
Check all that apply
Early Intervention
Home Visiting
Pre-natal and child health
Child Care Assistance
Child Care Access
Request for Additional Support
Request for Additional Support
Financial Support - Barrier Removal (Child Care, Transportation and Food )
Please identify the type of financial support that is needed to remove barriers to participation during your meeting.
Topic Specific Consultation/Coaching
Please indicate the consultation/coaching topic that we can help you with.
Translation of Materials
Please indicate the language(s) that would like the materials translated into.
Facilitation and/or Note-taking Support
Please indicate what type of support you are seeking.
Email Confirmation
Email Confirmation
Please check the box below and provide your email to receive a confirmation of your submission.
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