Lifted Logic Web Design in Kansas City
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Directors Leadership Academy
*
DLA 1 (eligable for $50 refund)
DLA 1
DLA 2 (eligable for $50 refund)
DLA 1 and 2
Participant
*
First
Last
Participant Email (for receipt)
Participant's Job Title
Highest Degree Earned
*
GED
High School Diploma
Some College
Associate's
Bachelor's
Master's
Doctorate
Degree Earned (Field)
How many staff do you (participant) supervise?
How long have you (participant) been working in early care and education?
*
Please indicate your (participant) age range:
*
18-24
25-54
55-64
65+
Please indicate your (participant) identified gender:
Female
Male
Please indicate your (participant) ethnicity:
American Indian/Alaskan Native
African-American
Asian/Pacific Islandere
Caucasian
Hispanic/Latino
What is the best way to reach you in case of a schedule change?
*
Which method would you prefer for receiving handouts?
Electronic
Hard copy (mailed)
Both
What are your preferred time sessions? Sessions are not interchangeable, participants will only be able to participate in one time slot over the course of the series.
First Choice
Thursday mornings (8:30 am--11:45 am)
Thursday afternoons (1:00 pm-4:15 pm)cond Choice
Thursday evenings (5:30 pm-8:45 pm)Choice
Second Choice
Thursday mornings (8:30 am--11:45 am)
Thursday afternoons (1:00 pm-4:15 pm)cond Choice
Thursday evenings (5:30 pm-8:45 pm)Choice
Program Name
*
Director's Name
*
Program Address
Street Address
Address Line 2
City
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Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Program Phone
Licensing Number
*
Total Licensed Enrollment:
How many children under age FIVE are enrolled (not enrolled in kindergarten)?
Do you accept children receiving state child care subsidies?
Yes
No
How many children ages 5 and under are currently receiving state child care subsidy?
First Choice
Second Choice
Third Choice
Is your program participating in CACFP?
Yes
No
Learn about CACFP here: https://www.thefamilyconservancy.org/child-care-food-program/
How many children ages 5 and under are on free and reduced lunches?
Do not include those who are not already counted in your state subsidy number.
How many children ages 5 and under that do not receive subsidy or qualify for free/reduced lunches through CACFP live in households with incomes less than $45,000 per year?
How many of the children enrolled are African-American?
*
How many of the children enrolled are Latino?
*
How many of the children enrolled are Caucasian?
*
How many of the children enrolled are of another ethnicity?
Please specify a number for each ethnicity type.
Total
$0.00
Coupon
Credit Card
*
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Expiration Date
Security Code
Cardholder Name
Total
$0.00
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