Child Care Health Consultation Summit 4 Registration

October 23rd, 2019 from 9:00 am-3:30 pm
Tukwila Community Center, 12424 42nd Ave S, Tukwila, WA 9816

We are thrilled that you will be joining us for the fourth summit to continue efforts that will strengthen and expand child care health consultation in King County. Thank you for taking the time to provide the following information. Please direct any questions to Soo Kim at soo.kim@kindering.org.

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone Number

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* 5. Organization

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* 6. Job Title

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* 7. Number of years working in the early learning field

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* 8. Please check the box below to let us know if you do not wish to share your contact information with other summit participants.

I DO NOT wish to share my contact information with other Summit participants.

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* 9. How would you describe your current role? (check all that apply)

Provide early intervention or special education services to children in child care settings

Provide child care

Provide some form of child care consultation and/or coaching services (e.g. nursing, infant and early childhood mental health, early care and education, etc.)

Design and/or implement policies

Fund programs and/or manage grants

Other (please specify)

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* 10. Do you work directly with children, families and/or child care providers?

Yes

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* 11. Please indicate if you would like interpretation services at the summit.

Yes, please follow up with me.

N/A

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* 12. In what language do you speak most fluently? (check all that apply)

Arabic

Amharic

Armenian

Chinese

English

French

French Creole

German

Greek

Gujarati

Hindi

Italian

Japanese

Korean

Oromo

Persian

Polish

Portuguese

Russian

Spanish

Somali

Tagalog

Urdu

Vietnamese

Other (please specify)

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* 13. Please indicate if you are a family child care provider and would like to request money to pay for a substitute.

Yes, please follow up with me.

N/A

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* 14. Please indicate all food allergies, intolerances and dietary requirements.

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* 15. Are there additional accommodations needed that you would like to request?

N/A

Yes. Please specify:

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* 16. Best Stars for Kids collects demographic data in order to keep track of who we are collaborating with and serving. It also allows us to see if we are achieving equity in our work.

(Optional) Please describe your race or ethnicity (check all that apply)

American Indian or Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Black or African American

Somali

Ethiopian

Hispanic, Latinx, or Spanish origin

Mexican

Mexican American or Chicano

Cuban

Puerto Rican

Native Hawaiian

Pacific Islander

Samoan

White

Middle Eastern

North African

None of the above, please specify:

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone Number

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* 5. Organization

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* 6. Job Title

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* 7. Number of years working in the early learning field

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* 8. Please check the box below to let us know if you do not wish to share your contact information with other summit participants.

Question Title

* 9. How would you describe your current role? (check all that apply)

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* 10. Do you work directly with children, families and/or child care providers?

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* 11. Please indicate if you would like interpretation services at the summit.

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* 12. In what language do you speak most fluently? (check all that apply)

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* 13. Please indicate if you are a family child care provider and would like to request money to pay for a substitute.

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* 14. Please indicate all food allergies, intolerances and dietary requirements.

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* 15. Are there additional accommodations needed that you would like to request?

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* 16. Best Stars for Kids collects demographic data in order to keep track of who we are collaborating with and serving. It also allows us to see if we are achieving equity in our work. (Optional) Please describe your race or ethnicity (check all that apply)

* 16. Best Stars for Kids collects demographic data in order to keep track of who we are collaborating with and serving. It also allows us to see if we are achieving equity in our work.

(Optional) Please describe your race or ethnicity (check all that apply)