Engagement Session Interest Form

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1. First Name (Required.)

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2. Last Name (Required.)

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3. Contact information (We will use this to contact you if you are selected to participate): (Required.)

Email address

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4. Phone number (optional)

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5. Session Dates - Please select ALL dates you are available to attend an engagement session. Choose all that apply. (Required.)

Monday, November 9, 1:00 to 2:15 pm

Tuesday, November 10, 6:00 to 7:15 pm

Thursday, November 12, 6:00 to 7:15 pm

Wednesday, November 18, 1:00 to 2:15 pm

Thursday, November 19, 6:00 to 7:15 pm (Session in Spanish)

Friday, November 20, 1:00 to 2:15 pm

None of the above

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6. Please indicate your preferred language for participating in an engagement session. This information will help us plan additional language supports for sessions. (Required.)

English

Cantonese

Mandarin

Russian

Spanish

Vietnamese

Other (type your response)

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7. Which of the following do you use to describe your race/ethnicity? (Required.)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic, Latino or Spanish origin

Native Hawaiian or other Pacific Islander

White

Multiracial

Prefer not to answer

Other (type your response)

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8. Current primary role (Required.)

Family child care owner/operator

Infant Toddler educator

Preschool educator

Kindergarten teacher

Child care/preschool director

Elementary school administrator

Coach or trainer

Parent, family member, or guardian

Other (type your response)

Tell us more! Your responses to the remaining questions will help ensure representation of Oregon’s families and communities in the engagement sessions.

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9. About how many years of experience do you have in this role?

Less than 1 year

1 - 5 years

6 - 10 years

10 years or more

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10. Type of setting where you work. Choose all that apply.

Family or home-based child care

Center-based care

Early Head Start or Head Start

Elementary school

Other (type your response)

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11. Where you work

If you work in multiple locations, please identify where you spend most of your time:

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12. Name of school, program, center, or family child care home

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13. In the last 3 years, to the best of your knowledge, have you worked with children from the following populations? Choose all that apply

Multilingual children

Children with disabilities

Children from families experiencing poverty

Children from families who are mobile

Children from Tribal communities

None of the above

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14. How frequently do you use the Early Learning and Kindergarten Guidelines in your role?

Never

Rarely

Occasionally

Frequently

I am not familiar with this document.

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15. What ages are the children you care for or support?
Choose all that apply

Birth to 3-year-olds

3- to 5-year-olds

5- to 6-year-olds

Older than 6 years old

Engagement Session Interest Form

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* 1. First Name (Required.)

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* 2. Last Name (Required.)

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* 3. Contact information (We will use this to contact you if you are selected to participate): (Required.)

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* 4. Phone number (optional)

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* 5. Session Dates - Please select ALL dates you are available to attend an engagement session. Choose all that apply. (Required.)

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* 6. Please indicate your preferred language for participating in an engagement session. This information will help us plan additional language supports for sessions. (Required.)

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* 7. Which of the following do you use to describe your race/ethnicity? (Required.)

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* 8. Current primary role (Required.)

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* 9. About how many years of experience do you have in this role?

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* 10. Type of setting where you work. Choose all that apply.

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* 11. Where you workIf you work in multiple locations, please identify where you spend most of your time:

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* 12. Name of school, program, center, or family child care home

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* 13. In the last 3 years, to the best of your knowledge, have you worked with children from the following populations? Choose all that apply

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* 14. How frequently do you use the Early Learning and Kindergarten Guidelines in your role?

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* 15. What ages are the children you care for or support?Choose all that apply

1. First Name (Required.)

2. Last Name (Required.)

3. Contact information (We will use this to contact you if you are selected to participate): (Required.)

4. Phone number (optional)

5. Session Dates - Please select ALL dates you are available to attend an engagement session. Choose all that apply. (Required.)

6. Please indicate your preferred language for participating in an engagement session. This information will help us plan additional language supports for sessions. (Required.)

7. Which of the following do you use to describe your race/ethnicity? (Required.)

8. Current primary role (Required.)

9. About how many years of experience do you have in this role?

10. Type of setting where you work. Choose all that apply.

11. Where you work

If you work in multiple locations, please identify where you spend most of your time:

12. Name of school, program, center, or family child care home

13. In the last 3 years, to the best of your knowledge, have you worked with children from the following populations? Choose all that apply

14. How frequently do you use the Early Learning and Kindergarten Guidelines in your role?

15. What ages are the children you care for or support?
Choose all that apply