Today's Date:____________
Name of program person who will serve as our primary contact:____________________________
Position of contact person:__________________________________________
Program Name/School District:_______________________________________
Name of classroom or group:_________________________________________
Address:________________________________________________________
City/Town/Zip:___________________________________________________
County:____________________________
Phone number:_______________________
Fax:_______________________________
E-Mail:_____________________________
LEARNS: Early Childhood and Child Care Plus ME: Maine’s statewide initiative to support meaningful and high quality early care and education and school age child care for children birth to 12 years. We provide technical assistance in the following areas:
Please check box(es) to indicate the type of assistance you are requesting:
| Age/Area of Focus | Information & Resources | Consultation for Child(ren) | Staff Development | Administrative Consultation |
|---|---|---|---|---|
| Infant-toddler care (6 weeks-3 years) | ||||
| Preschool care / Early education (3-5 years) | ||||
| School age child care (5-8 years/grades K-2) | ||||
| School age child care (9-12 years / grades 3-4) |
Level of Urgency of Request: ___ High ___ Medium ___ Low
For child specific consultations, please make sure that the parent(s) are aware of this consultation and appropriate releases are signed and returned with this form.
How did you hear about us?
1. What are your goals as a result of this technical
assistance? (please prioritize & please feel free to attach additional sheets of
paper if necessary)
(a)
(b)
(c)
2. What supports are in place or are you willing to commit to sustain your efforts toward these outcomes?
3. How will you measure progress toward your goals?
4. How will this technical assistance request relate to your other school initiatives?
5. How will you involve parents in the process?
For child(ren) specific consultation, please provide the following information:
Child's date of birth: __________
Is this child a state agency client? ______Yes ______No
Does this child have an identified disability? ______Yes ______No If yes, what?
Does this child, or any of the other children involved in this request, have (check all that apply):
_____ ASPIRE/TANF _____ Child care voucher _____ Contracted child care (subsidized)
_____ Foster Care Support _____ Waiting list for child care vouchers
To best support inclusive early care and education practices, please prioritize your top focus areas (1,2,3):
______ Involvement/participation in general ed. curriculum, Maine Early Childhood Learning Results
______ Assessment, observation, documentation
______ Accommodations, considering the environment, materials equipment, activities, instruction
______ Behavior, positive supports, improving child behavior and/or social skills, behavior management, classroom management
______ Communication skills, including augmentative, and assistive technology
______ Community building, classroom climate, relationships, friendships, peer interactions
______ Disability specific information
______ Health and medical information, including mental health
______ Americans with Disabilities Education Act (ADA) and/or Individuals with Disabilities Education Act (IDEA)
______ Emergent literacy
______ Parent/Family development, parental rights and responsibilities, surrogate/foster parents
______ Research based strategies, research based curricula and teaching practices
______ Teaming and collaboration
______ Transition planning, kindergarten planning
______ Other, please specify:
________________________________________________________
Signature of Executive Director or Superintendent of Schools
_______________________________
Date
Return the completed form to:
or Fax to: (207) 892-2330
For more information, contact:
For Office Use ONLY:
Date Received: __________ Reviewed by: _________________
Assigned to: _________________ Project: _____________________
File Number:_____________________
updated 3/15/2006