Home
Early Learning
Pan African Children United
Pan African Providers United
Scholarships
Chief Rufus Carter Sr.
Contact
Donate
Home
Early Learning
Pan African Children United
Pan African Providers United
Scholarships
Chief Rufus Carter Sr.
Contact
Donate
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
How do you identify?
*
African
Afro-Latino
Caribbean
Other
Black/African-American
Do you consider any country outside of America home?
*
Primary language spoken at home?
*
Do you need translation services? If so, what language?
*
Early Childhood Education Experience
Do you work in Washington County?
*
Yes
No
How do you work within Early Childhood Education
*
Registered Family licensed provider (RF)
Certified Family licensed provider (CF)
Early Interventionist
ECE Coach
Quality Improvement Specialist
Preschool Teacher
Infant Toddler teacher
Certified Childcare Center owner
Other
Name of Program or Organization
*
Address of your program or place of work
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
If you are a provider or other do you have a website?
*
Yes
No
Not applicable
Your website
http://
What Oregon Registry Online (ORO) Step do you hold?
*
I currently do not have a ORO Step
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10
Step 11
Step 12
Are you interested in becoming a Preschool Promise provider?
*
No
Yes
N/A
NBCDI Conference
Have you heard of the National Black Child Development Institute (NBCDI)?
*
No
Yes, but I am not a member.
Yes, I am a member.
Are you able to travel to St. Louis, Missouri July 24-27, 2024 for the conference.
*
Airfare will be covered by Fighting for Success Foundation
Yes
No
Are you okay with traveling on an airplane?
*
No
Yes
What barriers may prevent you from attending the conference?
*
Any other information you would like to share?
Central Background Registry Number (CBR)
*
Oregon requires any person 18 years and older working within Early Childhood Education to pass a background check. Please add your CBR number. It can be found in your Oregon Registry Online account.
Thank you!
