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1 Today s Date: 1. Name: Female Male 2. Social Security Number: Birth Date: 3. Address: City: State: Zip: County: 4. Phone Numbers Home: ( ) - Work: ( ) - Cell: ( ) - Fax: ( ) Employment Status: a. What is your job title? b. What age group do you provide care for? c. How many children are in your classroom? d. Beginning date of employment with current employer: (Month / Day / Year) / / e. What is your current hourly salary? (please attach pay stub) f. How many hours per week do you work? 7. Family Structure: (this information will be used for demographic purposes only) a. How many people live in your household? b. List everyone in your household and their relationship to you: 8. Ethnicity: Do you consider yourself...? American Indian (Tribe: ) Black/African American Other (please describe): Asian/Pacific Islander Hispanic/Latino Bi-racial White/European-American 1 Associate s Degree Teacher Application 5/30/2009

2 9. Name of Child Care Center: a. License/registration number: b. License/registration capacity: c. Current enrollment: d. Child Care Center address: City: State: Zip: County: e. Child Care Center f. Child Care Center Auspice: Profit Non-Profit Head Start Public Public School Registered Ministry g. Is your Child Care Center accredited? YES NO h. Is your Child Care Center enrolled in Paths to QUALITYTM? YES NO If so, at what Level is your Child Care Center? (circle the appropriate Level) Level 1 Level 2 Level 3 Level 4 (Accreditation) 10. Educational Background: High School Dates Attended Diploma (circle one) GED (circle one) Yes No Yes No College/University Dates Attended Major(s) Degree or Credit Hours a. Name of college/university you would like to attend? b. Location of college/university: c. When would you like to begin classes? (circle one) Spring (Jan-Apr) Summer (May-July) Fall (Aug-Dec) 11. Are you currently enrolled in an early childhood degree program at a college/university in Indiana? YES Describe how far you have progressed in this program? What classes have you completed? 2 Associate s Degree Teacher Application 5/30/2009

3 12. What are your professional goals in early childhood education? Describe how a degree will help you achieve these goals. Be sure to include your long-term career goals. 13. How did you find out about the Project? 14. Do you receive any other financial assistance (i.e. scholarships, grants, loans, etc.)? YES If yes, please list: 15. Why do you want to earn a degree in early childhood education? 16. Why should fund you over other applicants? 17. Do you and/or your family have any special needs or problems that you feel deserve extra consideration? 3 Associate s Degree Teacher Application 5/30/2009

4 Statement of Income Instructions: List sources of income available to you. For your source of income, you MUST provide a copy of verification of that income. A statement from your employer indicating your hours and rate of pay or most recent pay stub will verify earnings from a job. A. Earnings Job #1: $ per hour B. Name of Employer #1: (insert name of current employer) C. Number of Hours worked per week: D. Earnings Job #2: $ per hour E. Name of Employer # 2: F. Number of Hours worked per week: G. Are you a student? Yes No If YES, answer Questions H through J ~ If NO, skip Questions H through J and GO DIRECTLY to Question K H. Scholarship/Grant #1 $ I. Scholarship/Grant #2 $ J. Student Loan $ K. Child support/alimony $ L. TANF / SSI $ M. YOUR TOTAL INCOME (Add lines A M): $ N. TOTAL FAMILY INCOME (your spouse included): $ per circle one MONTH/YEAR Participation Agreement & Signature of Applicant I attest to the fact that the information that I have provided is true and accurate. Based on this information, I am applying to the for a scholarship to help pay the cost of educational expenses. I am aware that I may be required to pay a portion (10%) of the cost of tuition and books for courses leading to a credential/degree. I am also willing to continue to work at my sponsoring child care program for one year after completing 9 to 15 credit hours in one contract year. Signature of Applicant Date PLEASE ATTACH A COPY OF YOUR MOST RECENT PAY STUB HERE 4 Associate s Degree Teacher Application 5/30/2009

5 Center Participation Agreement (TO BE COMPLETED BY SPONSORING CHILD CARE CENTER CHAIRPERSON/OWNER) The Early Childhood Associate Degree Scholarship Program offered through the Indiana Association for the Education of Young Children, Inc. requires the participation of each scholarship recipient s employing child care center. In the event that (Applicant s Name) is awarded a scholarship, I understand that the center agrees to participate in one of the following ways: (Please check ONE to indicate which option you prefer): Option One 1. Pay 10% of the cost of tuition and books for courses totaling 9 to 15 credit hours at a college or university for the scholarship employee. 2. Provide paid release time each week for my scholarship employee. The amount of release time is equal to the number of credit hours the employee is taking up to a maximum of six (6) credit hours per week. 3. At the end of the year upon completion of 9 to 12 credit hours, award a 2% raise or a $300 bonus, or upon completion of 13 to 15 credit hours, award a 3% raise or a $400 bonus. CHECK ONE: Bonus Salary Increase Option Two 1. Pay 20% of the cost of tuition and books for courses totaling 9 to 15 credit hours at a college or university for the scholarship employee. 2. Provide paid release time each week for my scholarship employee. The amount of release time is equal to the number of credit hours the employee is taking up to a maximum of six (6) credit hours per week. 3. At the end of the year upon completion of 9 to 12 credit hours, award a 2% raise or a $300 bonus, or upon completion of 13 to 15 credit hours, award a 3% raise or a $400 bonus. CHECK ONE: Bonus Salary Increase Child Care Center Name: License/Registration Number: Child Care Center Address: City: State: Zip: County: Fax Number: ( ) - Child Care Center FOR ALL PROGRAMS Child Care Center Auspice: Profit Non-Profit Head Start Is Child Care Center Accredited: YES No Indicate Child Care Center Type: Licensed Head Start Registered Ministry School Enrolled in Paths to QUALITY? YES If YES, indicate current level (circle one): LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 (Accreditation) HEAD START or MULTI-SITE PROGRAMS MUST ALSO COMPLETE THIS BOX Is this Child Care Center/Program owned or managed by another organization? YES If YES, give the parent company name and address: FOR ALL PROGRAMS: Printed name of Chairperson/Owner: Signature of Chairperson/Owner: Return completed application with income verification to: ~ 4755 Kingsway Drive, Suite 107, Indianapolis, IN Questions? Please call (317) or (800) Fax: (317) Associate s Degree Teacher Application 5/30/2009

1. Name: Female Male. 2. Social Security Number: Birth Date: 3. Address: City: State: Zip: County:

1. Name: Female Male. 2. Social Security Number: Birth Date: 3. Address: City: State: Zip: County: Today s Date: 1. Name: Female Male 2. Social Security Number: Birth Date: 3. Address: City: State: Zip: County: 4. Phone Numbers Home: ( ) - Work: ( ) - Cell: ( ) - Fax: ( ) - 5. Email: @ 6. Employment

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