Kids on Campus Initiative

Kids on Campus Initiative
Interested in connecting with or learning more about the Kids on Campus Initiative? Please fill out the information below. If you have any questions, please e-mail kidsoncampus@acct.org
1. Name*

First NameLast Name
2. Job title*
3. Organization name*
4. Organization Type*
4. Organization Type*
If "Other" what type of organization is this?
5. Work e-mail*
example@example.com
6. City, State, Zip*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
7. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
8. What is your preferred contact method? (check all that apply)

EmailPhone
9. Please tell us how you and/or your organization would like to engage with Kids on Campus (check all that apply.)*

Community College interested in exploring a Kids on Campus partnership with a local Head Start provider.Head Start provider interested in exploring a Kids on Campus partnership with a local community college.Interested in providing funding to support Kids on Campus InitiativeWould like to be contacted to learn more about the Kids on Campus InitiativeWould like to receive updates about the Kids on Campus Initiative
10. Who is the best person to follow-up with about engaging, if not you?
Name

First NameLast Name
Email
example@example.com
11. Would you be available and willing to share your experiences in any of the following roles? (check all that apply)

A Head Start provider on a college campusAn existing community college and Head Start partnershipA student parent at a community collegeA Head Start parent attending or interested in attending a community collegeAn organization that has partnered to provide childcare on a college campus
12. How did you hear about the Kids on Campus initiative? Your response will help us track the effectiveness of our marketing and outreach efforts. (check all that apply)

ConferenceWebinarSocial mediaTraditional publication (newspaper, TV, radio)
13. Is there anything else you would like to share about your interest, organization, or experience with Head Start/Community College partnerships or providing access to childcare on a community college (i.e. CCAMPIS coordinator, part of the Head Start state association)?
Should be Empty:

Kids on Campus Initiative

Interested in connecting with or learning more about the Kids on Campus Initiative? Please fill out the information below. If you have any questions, please e-mail kidsoncampus@acct.org

10. Who is the best person to follow-up with about engaging, if not you?