National Education Association and Parent Teacher Home Visits Institute
Application Form
1. Your Information
1a. Name
First Name
Last Name
1a. Your Role in the Affiliate
1b. Email
example@example.com
1c. Cell Phone Number
Please enter a valid phone number.
2. Affiliate Information
2a. Name of your affiliate
2b. Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2c. Phone Number
Please enter a valid phone number.
2d. Total Membership
2e. Total Potential Members (i.e. current non-members)
2f. How many schools are in your district?
3. Current State
3a. Describe the degree to which your district engages families in their children’s education and in school-site or district-wide decision-making.
Not at All
1
2
3
4
Extremely Engaged
5
1 is Not at All, 5 is Extremely Engaged
3b. Describe your response to the scale above.
3c. Are home visits currently a family engagement strategy?
4. Purpose
4a. Why is participating in the Institute timely for your Local right now?
4b. What are your current family engagement goals and how will PTHV home visits help you achieve them?
5. Demographics
5a. What is the racial make-up of your members?
5b. What is the racial makeup of the District that will be touched through the Institute? What percentage of students qualify for free and reduced lunch?
6. Partners
6a. PTHV home visits work best when there is a strong local partnership among the local union, local community organization(s), and local school district. Who are the partners that you are working with – or hope to work with – in pursuit of launching or growing a PTHV home visit practice? How would you describe and assess your relationships with them (both current and historically)? If you do not have partnerships yet, that is okay. We can support you through that phase.
7. Participant Team
7a. Please list the members, staff, and partners who you are thinking about including on your Institute team. Teams are limited to a maximum of 10 people each, and all team members are expected to participate fully. We encourage careful, intentional consideration of the make-up of teams and attention should be given to establishing a team that reflects diversity in race, ethnicity, gender, age, and roles and responsibilities.
8. Commitment
8a. Financial: PTHV home visits require that educators are compensated for their home visit time. What is your plan to secure funding for this purpose (school districts typically use Title I family engagement funds, but other funding sources can be used as well)? If you do not currently have funding secured, you can still participate. The Institute can help you develop your plan for securing funding.
8b. Time: Are you and your team able to commit to attending the Institute’s monthly virtual meetings/trainings?
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