National Home Visiting Network: Parent Leader Application - Cohort 2

National Home Visiting Network

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1. Name (first and last) (Required.)

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2. Address (include City, State, Zip) (Required.)

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3. Email (Required.)

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4. Phone Number (Required.)

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5. What is the current age(s) of your child/children who received home visiting services? (Note: We are looking for parenting adults who currently have children enrolled in a home visiting program.)
(Required.)

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6. What is your relationship with the child/children in your care? (select one) (Required.)

Biological parent

Adoptive parent

Foster parent

Grandparent

Other family member

Other (please specify)

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7. Please specify your race/ethnicity. (Please select all that apply. Answer this question for yourself, not for the race/ethnicity of your children.) (Required.)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latino

Prefer not to say

Other (please specify)

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8. What home visiting resources/programs have you accessed/used? (Please select all that apply.) (Required.)

ABC

Child First

Early Head Start - Home Based

Family Connects

Healthy Families America (HFA)

Home Instruction for Parents of Preschool Youngsters (HIPPY)

Nurse-Family Partnership (NFP)

Parents as Teachers (PAT)

ParentChild+

SafeCare

Tribal Home Visiting

Welcome Baby

Other home visiting programs (please specify)

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9. What child care resources/programs have you accessed/used? (Please select all that apply.) (Required.)

Center-based

Family child care

Early Head Start

Head Start

State Pre-K

Other child care resources/programs (please specify)

None of the above

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10. What additional resources/programs have you accessed/used? (Please select all that apply.) (Required.)

Health care

Nutrition Assistance

Housing

Transportation

Income supports (such as TANF or unemployment)

Other resources/programs (please specify)

None of the above

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11. Are you connected to any national, state, or local parent affinity groups? (Examples: home visiting ambassador or alumni programs, parent/teacher organizations, formal and informal mom-and-me type groups, MomsRising, Parents Together, Parent Voices, United Parent Leader Network, or others.) (Required.)

Yes

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12. If yes, please share the name of the group, the purpose, how often it meets, how long you have been involved, and your role in the group.

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13. What do you hope to contribute to the National Home Visiting Network? (Required.)

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14. What do you hope to learn from serving on the National Home Visiting Network? (Required.)

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15. Will you be able to commit to three monthly virtual meetings, and one annual in-person meeting (for which overnight travel may be required)?
(Three monthly virtual meetings include the monthly meeting of the National Home Visiting Network Advisory Committee held on the third Wednesday of each month from 12:30-2 p.m. Eastern time, as well as a pre- and a post- meeting specific to parent leaders at a time to be determined.) (Required.)

Yes, I can commit to both the three virtual meetings each month and the future in-person meetings.

No, I cannot commit to this.

I can only commit to participating virtually.

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16. Do you have any concerns about serving as a parent representative on the National Home Visiting Network? (Required.)

Yes

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17. If yes, please share your concerns.

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18. Please share any additional questions or comments.

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19. Please provide a reference from your home visiting program. This may be your home visitor, the program supervisor, or program director. (Name, Email, Phone Number) (Required.)

National Home Visiting Network: Parent Leader Application - Cohort 2