FIRST 5 Programs for Family Child Care Home Providers - Participant Interest Form

Are you interested in participating in SEEDS of Learning for Family Child Care Home Providers or myTeachstone Program? If so, please complete this form.

Provider Information

First Name/Nombre*

Last Name/Apellido*

E-mail/Correo electrónico*

Phone Number/Número de teléfono*

What is your preferred language for training?/ ¿Cuál es el idioma que prefiere para el entrenamiento?*

English/Inglés

Spanish/Español

Facility Information

Name of Family Child Care Home/Nombre del hogar de cuidado infantil*

In what ZIP code is your child care home?/ ¿En qué código postal está su hogar de cuidado infantil?*

Are you a licensed child care provider?/ ¿Es usted un proveedor de cuidado infantil con licencia?*

Yes/Sí

No/No

What is your license number?/ Si contestó que sí a la pregunta anterior, ¿cuál es su número de licencia?*

What type of license do you have for your facility?*

Select

How many months of the year is your facility open?*

(Please enter a number 1-12. If you are closed for 2 weeks or less the entire year, enter 12)

Children Served

How many children do you have in your home between the ages of 0 and 2 years?/ ¿Cuántos niños entre 0 y 2 años tiene en su hogar?*

How many children do you have in your home between the ages of 3 and 5 years?/ ¿Cuántos niños entre 3 y 5 años tiene en su hogar?*

How many children do you have in your home 6 years or older?/ ¿Cuántos niños de 6 años o mayores tiene en su hogar?*

Do any of the children in your care have an IEP or IFSP?/ ¿Alguno de los niños bajo su cuidado tiene un IEP o IFPS?

I don't know/No sé

Yes/Sí

No/No

FIRST 5 Program Participation

Which FIRST 5 program are you interested in participating in?*

Select

Which Family Resource Center referred you to the SEEDS program? / ¿Qué Lo/la refirió al programa de SEEDS?

Select or enter value

If you chose "Other" in the question above, please provide the name of the person who referred you to SEEDS. / Si elegiste 'Otro' en la pregunta anterior, indique el nombre de la persona quien lo/la refirió a SEEDS.

Have you ever participated in SEEDS before, and in what year did you participate?/ ¿Alguna vez ha participado en SEEDS y en qué año participó?*

No- I have never participated in SEEDS before/No- Nunca antes he participado en SEEDS

Yes- 2016/Sí- 2016

Yes- 2015/Sí- 2015

Yes- 2014/Sí- 2014

Yes- 2013/Sí- 2013

Yes- 2012/Sí- 2012

Yes- I don't remember what year/Sí- No recuerdo en qué año

Acknowledgement

By checking this box, I acknowledge that SEEDS of Learning and myTeachstone programs require a year-long commitment. / Al marcar la casilla de abajo, reconozco que el entrenamiento de SEEDS de Alfabetización Temprana requiere un compromiso de un año.*

If I participate in myTeachstone, I understand that I am required to have an email account, attend a myTeachstone orientation, and watch at least 15 minutes of myTeachstone videos per week.*

If I participate in SEEDS of Learning, I understand that I am required to attend workshops and be available for coaching visits in my home. Entiendo que se me solicitará asistir a los talleres y estar disponible para las visitas de entrenamiento en mi hogar*

Send me a copy of my responses

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