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Shared Services Licensing Support -About You
Demographic Information
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* Indicates required question
Name
*
Your answer
Email
*
Your answer
Phone
Your answer
Address: Street/City/Town
*
Your answer
Zip Code?
*
Your answer
Age
*
18-25 years old
26-35 years old
36-45 years old
46-55 years old
56-65 years old
66-75 years old
Prefer Not to Answer
With which gender identity do you most identify?
*
Female
Male
Non-Binary
Prefer Not to Answer
Race and Ethnicity (Check all that apply)
*
American Indian or Alaska Native
Asian or Asian American
Black or African American
Native Hawaiian or Other Pacific Islander
White
I prefer not to answer
Other:
Are you of Hispanic or Latino origin? (check one)
*
Hispanic or Latino origin
Not Hispanic or Latino origin
Prefer not to answer
Do you identify with any of the common ethnicities in Boston listed below? (check all that apply, leave blank if not applicable)
*
Cape Verdean
Middle Eastern or North African
Chinese
Indian
Vietnamese
Dominican
Haitian
Jamaican
Puerto Rican
Brazilian
Colombian
Salvadorian
Not applicable, I do not identify with an ethnic identity other than my race
Prefer not to answer
Other ethnicity not listed here
Other:
Required
In which language do you prefer to communicate?
*
English
Spanish
Other:
What is your highest Education level?
*
Less than High School
High school (or GED)
Some college, no degree
Child Development Associate Certificate (CDA)
Associate degree
Bachelor's degree
Master's degree
Teacher Lead
Director Certificate
License for Family Childcare
Other:
Do you have experience working in the field of early childhood?
Yes
No
Clear selection
If yes, please tell us about your early childhood experience including where and how many year.
Your answer
Do you have an EEC certification?
Prior family childcare provider license
Approved family childcare assistant license
Center-based teacher
Center-based lead teacher
Center-based Director I?
Center-based Director II?
Clear selection
When are you planning to open your family childcare business?
As soon as possible
During the next 6 months
Within the next 2 years
Other:
Clear selection
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