MSPA Application Maine State Parent Ambassador Application 2023-2024 "*" indicates required fields Name* First Last Email* Phone*Address* Street Address City State ZIP / Postal Code Home Language* Other Languages Allergies/Food RestrictionsMy child is enrolled in:* Head Start Early Head Start Child care Home Visiting program Foster Care Subsidized Child Care Private pay preschool Public preschool Family/friend/neighbor child care My child is not enrolled in a program Other What are the ages of your children? Check all that apply.* 0-2 3-4 5-8 9-12 13-17 18+ Household MembersPlease list all household members.Name 1 NameAge 1 AgeSchool/Work 1 School / workplaceRelationship 1 Relationship to youName 2 NameAge 2 AgeSchool/Work 2 School / workplaceRelationship 2 Relationship to youName 3 NameAge 3 AgeSchool/Work 3 School / WorkplaceRelationship 3 Relationship to youName 4 NameAge 4 AgeSchool/Workplace 4 School/WorkplaceRelationship 4 Relationship to youDescribe yourself in three words:* Why would you like to be a Parent Ambassador?*Tell us what talents and skills you would bring to the program:*Employment/School/Volunteer work history:*Tell us your experience working as a team or in the community:*How do you manage opposing points of views? How do you manage conflict and/or frustration?*What does early learning mean to you?*What does it mean to you to have a commitment to diversity? How have you demonstrated or see yourself demonstrating that commitment?*Please share your race and ethnicity* American Indian or Alaska Native Asian or Asian American Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White or Caucasian Other Expectations of being a Parent Ambassador include; Check all that apply to you:* I can attend bi-monthly meetings via Zoom I can attend in-person workshops (four 2-day workshops per year -- Friday/Saturday) I will secure child care for my children so I can attend the workshops I can make the one year commitment I will check my email regularly I have internet access I have an infant that will need to attend meetings with me (This does not affect your application, we just need to know for planning purposes) The Maternal and Child Health Evaluation Team may contact me for a focus group or interview:* Yes No