Division for Early Childhood Community of Practice Facilitator Application

Division for Early Childhood Community of Practice Facilitator Application
Individuals interested in becoming a Division for Early Childhood (DEC) Community of Practice (CoP) facilitator or co-facilitator should provide their demographic information before proceeding to the remaining questions which will serve as a letter of interest. Note that anyone serving in a leadership role as a CoP Facilitator must be/become a DEC member.
What is the name of the CoP you are interested in facilitating?*
Name*

First NameLast Name
Email*
example@example.com
Role/Title*
Phone Number*

Area CodePhone Number
Geographic Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
CEC/DEC Membership

You do not need to be a CEC/DEC member to apply but you do need to be/become a member to be a CoP Co-Facilitator.
CEC/DEC Member ID
Membership Expiration Date

MonthDayYear
Date
Demographic Information

The next three questions are optional.
Gender (Optional)
Race/Ethnicity (Optional)
Do you identify as disabled or having a disability?

YesNoPrefer No to Answer
Title/Role: (Select your current primary role)*

Administrator/CoordinatorAdvocateAssociation LeaderBehavior Specialist/Mental HealthChild Care ProviderConsultant/Trainer/TA ProviderEarly Childhood EducatorEarly Childhood Special Education TeacherEarly Intervention PractitionerElementary Special Education Teacher (5+)Family MemberHead Start/Early Head Start ProviderHealth Care Provider/Public Health ProfessionalHigher Education FacultyOccupational TherapistParaprofessionalPhysical TherapistPolicymakerPsychologist/School PsychologistResearcherService CoordinatorSocial WorkerSpeech and Language TherapistState Administrator/StaffStudentOther
If you did not select family member above, are you also a family member of a young child with a disability?*

YesNo
What age range matches your primary expertise?*

0-3 Early Intervention3-5 Early Childhood Special Education0-5 Early ChildhoodKindergarten - 3rd Grade
How long have you been a member of this CoP?*

This is a new CoPLess than 1 year1-3 years4-6 years6-10 yearsMore than 10 yearsI am not a member of this CoP
Letter of Interest
Why are you interested in serving as a CoP facilitator or co-facilitator?*
What special skills or knowledge base will you bring to the CoP as a facilitator or co-facilitator (e.g. strong leadership skills, well prepared/organized, good communication skills, technological skills, extensive experience in shared interests/practices of CoP members, etc.)? *
What strategies will you use to engage and support CoP members around their shared interests and practices?*
How will your commitment to equity tie into your work as a CoP facilitator or co-facilitator?*
If you are applying for the Service Coordination CoP, describe your experience with service coordination in early intervention.
Select the one that best describes the average amount of time you can volunteer as a CoP facilitator or co-facilitator.*

1-3 hours a month4-6 hours a month7-10 hours a monthOther
Select the one that best describes the length of time you would like to serve as a CoP facilitator or co-facilitator.*

1-2 years2-3 years
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