MOYC Share Your Story Application

This application gathers information for sharing your story for April's Month of the Young Child. After you provide information, a staff member will contact you on next steps.

If you have questions, you can contact Mary at marhal@pakeys.org or 717-213-2077.

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* 1. Please share your contact information

First and Last Name

County

Email Address

Phone Number

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* 2. Please select the program(s) you represent. Select all that apply.

PA Pre-K Counts

Home Visiting

Certified/Licensed Child Care (Keystone STARS)

Head Start

Early Intervention

Child Care Works (subsidized child care)

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* 3. Do you represent a parent/family member or a professional?

Parent/family member. If you selected this option, please skip to Question #5

Early Childhood Education Professional

Other. Please specify.

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* 4. How long have you worked serving families/children?

Less than one year

1-4 years

5-9 years

10 years or longer

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* 5. Please select the age range of your child or children you have (if a parent/family member) or you serve (if a professional). Select all that apply.

Birth to two years old

Two to three years old

Three to four years old

Four to five years old

Older than five years old

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* 6. Parent/Family member: Please briefly share the way this program has made an impact in your life or your child's life.

Professional: Please briefly share the way your work has impacted your life or the lives of those you serve.

(If selected, you will have the opportunity to go into more details during the interview.)

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* 7. Please select your ethnicity (optional)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 8. Please select which option best fits you.

You have the option to be considered to do a video recording of your story in Harrisburg, PA. Video recordings will be conducted during March 2020. If selected, participants will receive a $200 stipend for their video recording participation. (Limited participation)

You also have the option to share your story in written form only. Sharing a written story can be done via email and it is not necessary to come to Harrisburg. You will have the option to share your full story and an optional photo. You will be contacted with more information. Written form is not eligible for the $200 stipend.

Yes, I would like to be consider for a video recording of my story.

No, I'm not interested in a video recording of my story, but I would like to share it as a written story.

I'm not sure--contact me to tell me more!