First Name / Nombre
Last Name / Apellido
Email / Correo electrónico
Address / Dirección
City / Ciudad
State / Estado
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip / Código postal
Phone / Número de teléfono
Best time to reach you? / ¿Mejor tiempo para llamarle?
Morning
Afternoon
Evening
Primary Language / Idioma de Preferencia
English
Spanish
Race and/or Ethnicity / Raza y/o Etnicidad
Asian
Black/African American
Chose not to respond
Hispanic/Latino
Multi-racial
Native American/American Indian/Alaskan Indian
Native Hawaiian/Pacific Islander
Other
White
Marital Status / Cuál es tu estado civil?
Single
Married
Education / ¿Tiene alguno de los siguientes estudios?
CDA (Child Development Associate)
Some College Credits
Associate Degree
Bachelor Degree
Master's Degree
None of the Above
Please list the title of your major(s) that correspond with the question above. (If Applicable) / Por favor de enlistar los títulos de su enfoque de matrícula que corresponde con la pregunta arriba. (Si aplica)
Please choose the option that best describes your current situation: / Por favor elija la opción que mejor describe su situación al momento:
I provide child care in my own home.
I provide child care at a residence other than my own home.
I provide child care at a center.
I do not currently provide child care.
How old are the children you serve? (If applicable, select all that apply) Rango de edad de los niños que atienden?
Infant / Infantes
Toddler / Niños pequeños
Preschooler / Niños en edad preescolar
School-Age / Edad escolar
Hours of Operation / Horario de atención
Days of Operation (Please select all that apply) / Días de operación
Sunday / Domingo
Monday / Lunes
Tuesday / Martes
Wednesday / Miércoles
Thursday / Jueves
Friday / Viernes
Saturday / Sábado
Business Structure / Estructura del Negocio
Sole Proprietor/Individual / Propietario único/Individual
Partnership / Sociedad
LLC
S Corporation / Corporación S
Don't Know / NO SABE
Do you have a Nebraska child care license? / Tiene una licencia de cuidado infantil de Nebraska?
Yes
No
Child Care License Type / Elija qué licencia tiene
FCCI
FCCII
Preschool-Only
Center
Operating as License Exempt / Si no es así, ¿opera actualmente como exento de licencia?
Yes
No
Don't Know
License Number / Número de licencia
Do you accept Child Care Subsidy (Title XX)? ¿Acepta el subsidio para el cuidado de niños (también conocido como Título XX)?
Yes, children in care / Si, si tiene niños (as) en la actualidad
Yes, no current children in care / Si, no tiene niños (as) en la actualidad
No
Don't Know / No Sabe
Do you participate in Step Up to Quality? / ¿Participa en Step Up to Quality?
Yes
No
Don't Know / No Sabe
What step are you? / ¿En que paso está usted?
Do you Participate in CACFP? / ¿Participa en el programa de comida (siglas en ingles CACFP)?
Yes
No
Don't Know / No Sabe
Currently work a job outside child care / ¿Trabaja actualmente en un trabajo diferente del cuidado de niños?
Yes, Full Time / Si, tiempo completo
Yes, Part Time / Si tiempo parcial
No
How did you hear about us? / ¿Cómo se enteró de este programa?
Advertisement / Anuncio
Colleague, Friend, Co-worker / Colega, amigo, compañero de trabajo
Conference / Conferencia
Mailing or Newsletter / Boletín
Other State/Local Organization or Agency / Otra organización o agencia estatal/local
Social Media (Facebook, Pinterest, Instagram, etc) / Redes sociales
Training or Professional Development in my State / Formación o desarrollo profesional
Web or online search / Búsqueda online
Word of Mouth / De boca en boca
Which additional NECC Child Care Network programs are you interested in? / ¿En qué programas de NECC Red de proveedores de cuidado infantil familiar está usted interesado?
NECC's Business Training Series / Consultation
Licensing Toolkit (Unlicensed Programs Only)
Professional Development Training
Child Development Associate (CDA) Training
Innovation Ambassador
Other (Please specify below)
Other (Please specify) / Otro (Por favor de detallar)
Registered with the Nebraska Exchange
I have registered with the Nebraska Early Childhood Exchange at nebraskaexchange.org / Me registre con el Nebraska Early Childhood Exchange en la página web nebraskaexchange.org
Photo Release / Permiso de Fotografía
NECC may use my photograph, likeness, artwork, profile and/or story in all media forms and any promotional materials. I understand I will not be compensated for this use. I waive any right to approve the final product, including any written copy. / Permis
General Consent / Release of Information / Consentimiento general / Divulgación de información
NECC may release my membership status including contact information to partner agencies, with which it has a signed agreement, for the purpose of providing other resources I may qualify for. Release will remain in effect until I revoke consent in writing.
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