Western New York Parent Leader Institute Application 2020

Searching for a way to influence positive change?
Want to become more involved in your child’s school or district?
Want to be a better leader in your family, neighborhood, and community?

Application Deadline: July 16, 2020

For more information call 716-332-4170 or info@parentnetworkwny.org

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* 1. Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Ages of Child(ren)

0-2

3-5

6-11

12-14

15-18

18-26

27+

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* 3. My child(ren) attend(s)

Early Intervention

PreSchool

Public School

Private School

Charter School

Home Schooled

Is not in school

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* 4. Are there any special accommodations necessary for you to participate?

Yes

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* 5. If yes, please specify (e.g., accessibility, interpreter, transportation, etc.)

This information provided will help The WNY Parent Leader Institute select participants.

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* 6. What are the reasons you want to participate in the program?

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* 7. What do you hope to learn?

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* 8. How do you plan to use what you learn?

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* 9. Do you think there will be any potential barriers to participating and meeting the requirements?

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* 10. What skills/knowledge do you bring to the program?

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* 11. Have you participated in any groups (parent groups, committees, etc)?

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* 12. List any volunteer roles (current and past)

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* 13. Education

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* 14. What else do you want the instructor to know about you/your reasons for participating in the program?

Members of the class will be provided with a Tablet to utilize throughout the series. WiFi is required.

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* 15. Please confirm your commitment to the WNY Parent Leader Institute Program by checking each of the expectations on the space provided and signing the form where indicated.

I agree to:

actively participate in all 4 online sessions to be held between 9:00 am and 4:30 pm (with breaks) on Saturdays: August 15, September 12, October 3 and November 7.

arrive on time and prepared for all sessions

participate in group activities and complete any pre-work for upcoming classes

keep an electronic leadership log throughout the program

identify how I plan to use what I have learned and create a goal leading to a project that will be shared with the group

participate in the evaluation process by completing the evaluation forms and giving feedback

maintain confidentiality within the group

participate in the graduation celebration on Saturday, November 14, 2020 time to be determined

return the tablet if all of the requirements are not met. In the event that the device is broken or damaged I agree to reimburse the program in the full amount.

Please print your full name and date

Funded by Mother Cabrini Health Foundation

Question Title

* 1. Contact Information

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* 2. Ages of Child(ren)

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* 3. My child(ren) attend(s)

Question Title

* 4. Are there any special accommodations necessary for you to participate?

Question Title

* 5. If yes, please specify (e.g., accessibility, interpreter, transportation, etc.)

Question Title

* 6. What are the reasons you want to participate in the program?

Question Title

* 7. What do you hope to learn?

Question Title

* 8. How do you plan to use what you learn?

Question Title

* 9. Do you think there will be any potential barriers to participating and meeting the requirements?

Question Title

* 10. What skills/knowledge do you bring to the program?

Question Title

* 11. Have you participated in any groups (parent groups, committees, etc)?

Question Title

* 12. List any volunteer roles (current and past)

Question Title

* 13. Education

Question Title

* 14. What else do you want the instructor to know about you/your reasons for participating in the program?

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* 15. Please confirm your commitment to the WNY Parent Leader Institute Program by checking each of the expectations on the space provided and signing the form where indicated. I agree to:

* 15. Please confirm your commitment to the WNY Parent Leader Institute Program by checking each of the expectations on the space provided and signing the form where indicated.

I agree to: