African American Provider Network – Provider Membership Form

Cost: Services are offered at no cost to African American Provider Network members.

Eligibility: Membership is open to Black/African American child care providers, educators and students interested in advancing their careers in Early Care and Education.

Examples of Membership Benefits:

Opportunities to share experiences/best practices in the Early Care and Education industry
Opportunities to earn additional revenue for providing coaching and mentoring to prospective child care providers
Tuition-free no cost enrollment in the ECE apprenticeship program that includes college registration, tuition, books, tutoring, coaching, etc.
Members-only online portal with a repository of resources including an online membership community to network amongst peers
Quarterly training and professional development sessions
Individualized and group coaching and mentoring sessions
Monthly meetings that improve your capacity as an ECE professional
Networking opportunities with legislators, corporate partners and stakeholders
Member small business spotlight

Are you Black/African American?*

YesNo

Name*

First NameLast Name

Cell Phone Number*

Please enter a valid phone number.

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your business phone number the same as your cell phone number?*

YesNo

Business Phone Number*

Please enter a valid phone number.

Is your business address the same as your home address?*

YesNo

Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Age:*

25 yrs and under26 yrs - 40 yrs41 yrs - 55 yrs56 yrs and over

What type of ECE professional are you?*

Are you currently providing child care services in the Crystal Stairs service area?*

YesNo

If you are not operating in Crystal Stairs service area, which R&R are you affiliated with?

How many years have you been a child care provider?*

What is the capacity of your child care program?*

Number of children served? (If none, put NA)

What is your current enrollment?*

If none, put NA

What type of facility do you have?*

Center-BasedHomeN/A

How many staff do you have, including yourself?*

If none, put NA

What Crystal Stairs programs are you affiliated with?*

Resource & ReferralChildcare Subsidy & Payment AssistanceCommunity VoicesParent Support Services ProgramHead Start / Early Head Start / CCPQSLA (Quality Start LA) - Provider Coaching Services

Are you credentialed or do you have a degree?*

YesNo

Do you have early childhood education (ECE) units?*

YesNo

How many?*

If none, put NA

Are you interested in enrolling in school to obtain ECE educational units?*

YesNo

What would you like to do in the ECE field (become a teacher, director, FCCH provider, etc.)*

How would you like to enhance or improve your child care business?*

Do you wish to obtain your child care license?*

YesNoI already have a license

Are you interested in participating in an apprenticeship (guided career development plan including college coursework, mentorship, on-the-job training, & skill development)?*

YesNo

Do you have any areas of expertise that you would like to share with other child care providers?*

YesNo

If so, please describe your expertise...*

If none, put NA

Are you interested in being coached and/or mentored?*

YesNo

Are you interested in coaching and/or mentoring other child care providers? *

YesNo

Would you like to have student interns in your program?*

YesNo

Which of the following timeframes work best with your schedule for AAPN related meetings and/or events?*

Weekdays (during work day)Weekdays (after hours)Saturday

Please provide contact information for additional providers that may benefit from the AAPN.

Please include all information ( First and Last Name | Contact Number | Email )

SIGNATURE*

African American Provider Network – Provider Membership Form

Benefits of Membership

Member Contact Information:

Member Profile

Education and Career Goals