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English (US)
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Somali
French (France)
Professional Pathways Application
Please complete this form to apply for State Approved Trainer and/or mentorship opportunities
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
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
State
Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Which professional pathway(s) are you intersted in?
Becoming a State Approved Trainer
*
Becoming a Lead Mentor for Shared Services
*
Becoming an Imagine U Mentor
*
Page 1: Summary Score
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Provider History
We want to learn more about your experience working in the early learning field
Are you currently a licensed family home child care provider in Washington State?
*
Yes
No
P2: Current LFCCP?
My experience in early learning includes: Check all that apply
*
Yes
No
Licensed Family Child Care Provider
Licensed Family Child Care Assistant
Early Learning Center Owner
Early Learning Center Director
Early Learning Program Supervisor
Early Learning Lead Teacher
Early Learning Assistant Teacher
Family Friend and Neighbor Provider
None of the above
What is your STARS ID number?
*
How long have you been a licensed childcare provider?
*
Less than 2 years
2 years to less than 5 years
5 years to less than 10 years
10 years to less than 15 years
15 years or more
P2: Time as LFCCP
Do you currently serve subsidized children?
*
Yes
No
SSPS Number
FamLink ID/License Number
What is your current Early Achiever's rating?
*
Unrated
Level 2 (Only select this level if you have been rated a level 2)
Level 3
Level 4
Level 5
P2: EA rating
What language(s) do you prefer to train or mentor in? Select all that apply
*
Yes
No
Arabic
Chinese (Cantonese)
Chinese (Mandarin)
English
Farsi
Oromo
Somali
Spanish
French
Page 2: Langauge Score
Page 2: Summary Score
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Pre-Requisites
Do you have a CDA or Initial Certificate?
*
Yes
No
Have you completed a three-credit Relationship-Based Peer Mentorship Course (RBPD) or participated in 15 hours of RBPD with the Imagine Institute?
*
Yes
No
No - But I have registered for a session
P3: RBPD
Do you have any other ECE specializations or certifications (for example, CPR, Trauma informed practices, etc. )
*
Yes
No
Are you are DCYF-approved STARS trainer?
*
Yes
No
Page 3: STARS trainer
What is your Trainer Level?
*
Level 1
Level 2
Level 3
Level 4
Level 5
Other
What ECE specializations or certification have you acquired?
*
Page 3: Summary Score
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Comfort with Technology
Do you have access to any of the following? Please select all that apply
*
Yes
No
Smartphone
Tablet/IPad
Computer
Reliable Internet (Wifi Hotspot)
P4: Tech Access
How comfortable are you with using the following digital platforms or handling the following tasks
*
No Knowledge
Limited knowledge
Basic Knowledge
Advanced Knowledge
Using computers, the internet and online tools
Sending and receiving emails
Managing an online calendar
Using Microsoft Word or other word processing applications
Using Microsoft Excel of other spreadsheet applications
Using Zoom or other virtual meeting software
P4: Digital Platforms
How comfortable are you with using the following ECE Technologies?
*
No Knowledge
Limited knowledge
Basic Knowledge
Advanced Knowledge
Navigating the MERIT system
Using DCYF's student Portal
Using Coaching Companion
Using WA Compass
Using SSPS
Using KidKare
P4: ECE Tech
Page 4: Summary Score
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State Approved Trainer Application
What trainer types are you interested in becoming?
*
Private Trainer
Imagine Institute Trainer
Other
Monthly participation is a part of the program. Can you commit to a monthly 1 hour TA session AND 5 hours of training EVERY OTHER month?
*
Yes
No
Maybe
Do you have experience training adults?
*
Yes
No
What experience do you have with adult learning?
*
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Mentorship Application
My preference (first choice) for mentorship is...
*
Please Select
Mentor or Speciality Mentor
Associate Mentor - Imagine U
Lead Mentor - Imagine U
My second choice would be
Please Select
Mentor or Speciality Mentor
Associate Mentor - Imagine U
Lead Mentor - Imagine U
In the Imagine U program, Mentors who have identified an intern they wish to work with may be prioritized in the application process. Do you have an intern identified that you wish to work with?
*
Yes
No
Please add the full name along with the contact information (email address or phone number) for each intern you wish to work with in the Imagine U program. Be sure to ask your intern to complete the intern application on the Imagine website: https://imaginewa.org/become-anintern/
*
Do you have previous experience as a mentor in Imagine U?
*
Yes
No
P5: Previous Experience
How many years have you participanted as a mentor in Imagine U?
1
2
3
4
5+
P5: Years of experience
How many years have you participated as a mentor in Imagine U?
*
Are you interested in mentoring more than one intern at a time?
*
Yes
No
Would you be interested in being a mentor who specialized in any of the following areas?
*
Business and Finance
Marketing and Communications
Trauma Informed Care
Lead Mentor Coordinator
I don't know/Unsure
Are you able to complete a monthly form detailing your work as a mentor?
*
Yes
No
P5: Monthly Reporting
Page 5: Total
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Demographic Questions
The Imagine Institute is dedicated to racial equity and inclusion. Whenever possible, the organization will collect both racial/ethnicity demographics of program participants and primary language preferences to determine the impact of services and opportunities provided to early childhood educators and contractors in Washington State.
Which demographic categories below apply to you?
*
American Indian/Indigenous American or Alaskan Native
East or Southeast Asian
Black or African American
Hispanic, Latino, or Spanish Origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
South or Central Asian
White
I prefer not to answer
Additional category not listed
What is your highest grade or year of school completed?
*
Not a high school graduate
High School Graduate
Some College
College Graduate or Higher
I prefer not to answer
Which category best describes your current age?
*
18 - 24
25 - 54
55 or over
I prefer not to answer
Which gender identity categories below apply to you?
*
Female
Male
Non-binary / gender-fluid
Prefer not to answer
Which pronouns do you prefer?
He/his
She/her
They/them
I prefer not to answer
What language(s) do you speak? Please choose all that apply.
*
Arabic
Chinese (Cantonese)
Chinese (Mandarin)
English
Farsi
French
Khmer
Oromo
Russian
Somali
Spanish
Tagalog
Vietnamese
Additional language not specified
I prefer not to answer
The following question is about health problems or impairments you may have. Are you limited, in any way, in any activities because of physical, mental or emotional challenges?
*
Yes
No
I prefer not to answer
Mentor Summary Score
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