Associate Degree Scholarship Application Checklist

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1 Associate Degree Scholarship Application Checklist Please submit all of the following information with your completed application. Complete application (all sections completed) Copy of child care center/family child care facility license Copy of all college/university transcripts Proof of enrollment or acceptance at a participating WV community college (letter of admission or current transcript) Statement of income completed (p. 3 of application) Most recent pay stub Program participation agreement completed and signed (pp. 4 & 5 of application) Scholarship/grant award letter (if applicable) Proof of applying for FAFSA (Free Application for Federal Student Aid). The confirmation page may be printed when applying online. Visit: For assistance with completing the application, contact: T.E.A.C.H. Early Childhood WV/River Valley Child Development Services Phone: Fax: attn: T.E.A.C.H. T.E.A.C.H. Early Childhood WEST VIRGINIA is a licensed program of Child Care Services Association. 1 Associate 12/2014

2 Employment Status T.E.A.C.H. Early Childhood WEST VIRGINIA Name Address City, State, Zip County Phone Number Home: Work: SSN Date of Birth (mm/dd/yyyy) Gender Date: What is your current job title? Teacher Assistant Teacher Administrator Family Based Professional n-teaching Professional Staff n-teaching Support Staff What age groups do you teach? (please check all that apply) Infants (0-12 Months) Toddler (13-36 Months) Is your center a WV Pre-K site? Yes Preschool (37 Months PreK) School Age Are you a teacher in a WV Pre-K Classroom? Yes How many children are in your classroom or child care home? How many hours per week do you work? How many months per year do you work? Beginning date of employment at current facility? What is your current hourly wage? How long have you worked in the field of early childhood? Less than 2 Years 2-5 Years 6-10 Years 10+ Years Ethnicity Are you of Hispanic, Latino or Spanish origin? Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Other Hispanic, Latino or Spanish Do you consider yourself.? White Black, African Am. Or Negro American Indian or Alaska Native Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan Other Asian: Other Pacific Islanders: Other race: How did you hear about the T.E.A.C.H. Early Childhood Project? Presentation My Center Director Mailing T.E.A.C.H. Recipient CCR&R Agency Workshop College Website Other (please specify): 2 Associate 12/2014

3 Please check the box that best describes your educational history: high school diploma Associate Degree High school diploma/ged (Major: ) 1-year certificate Bachelor Degree ACDS certificate (Major: ) Masters (Major: ) Doctorate Please check one that best describes your educational goals: Earn an Early Childhood or School-Age Credential Take a few early childhood courses to obtain or upgrade job-related skills Earn an Early Childhood, Infant/Toddler or School-Age Certificate Earn an Early Childhood Associate Degree Earn an Early Childhood Associate Degree and transfer to a four-year college/university to earn a Bachelor s Degree Earn a Bachelor s Degree Are you currently enrolled at a community college? Yes When would you like your scholarship to begin? FALL SPRING SUMMER (year) Which Community College would you like to attend? Statement of Income Job #1 Employer Hours/Week Earnings per Job #2 Employer Hours/Week Earnings per Have you applied for any other financial aid (such as Pell Grants, Smart Start Grants or student loans)? YES NO Source of financial aid #1 Date of application Application Status: AWARDED DENIED PENDING Source of financial aid #2 Date of application Application Status: AWARDED DENIED PENDING YOUR TOTAL INCOME $ YOUR TOTAL FAMILY INCOME (your spouse included) $ STATEMENT & 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 River Valley Child Development Services for a scholarship to help pay the cost of educational expenses. Signature of Applicant Date PLEASE ATTACH A COPY OF YOUR MOST RECENT PAY STUB HERE 3 Associate 12/2014

4 Program Participation Agreement The T.E.A.C.H. Early Childhood Associate degree scholarship program offered through River Valley Child Development Services requires the participation of each scholarship recipient s employing child care center/pre-k/head Start program/family facility. In the event that is awarded a scholarship, I understand that the program agrees to participate in one of the following ways: (Please check one to indicate which option you prefer) Director is employee of center. Model One Pay 10% of the cost of tuition for 12 credit hours at a participating community college for the scholarship employee. At the end of the contract term, upon completion of 12 semester hours, award a $150 bonus to the scholarship employee. Director is also owner of center. Model Two Pay 20% of the cost of tuition and 10% for the cost of books for 12 credit hours at a participating community college for the scholarship recipient. Teacher Model One- (2% Raise) Pay 10% of the cost of tuition for a minimum of 9 credit hours at a participating community college for the scholarship employee. Provide paid release time each week for the scholarship employee. The amount of release time is equal to the number of credit hours an employee is taking, with a maximum of 3 hours per week. Release time will be provided when the community college is in session. At the end of the contract term, upon completion of 9 credit hours, provide the scholarship employee a 2% raise at the beginning of the seventh month of the commitment period. This raise is above and beyond any other expected raise. Teacher Model Two- ($300 bonus) Pay 10% of the cost of tuition for a minimum of 9 credit hours at a participating community college for the scholarship employee. Provide paid release time each week for the scholarship employee. The amount of release time is equal to the number of credit hours an employee is taking, with a maximum of 3 hours per week. Release time will be provided when the community college is in session. At the end of the contract term, upon completion of 9 credit hours, provide the scholarship employee a $300 bonus at the beginning of the seventh month of the commitment period. Please Print name of Director/Owner: Signature of Director/Owner: 4 Associate 12/2014

5 Program Name Program Type Center Facility Head Start Pre-K Address City, State, Zip County Phone Number Home: Work: Program Director Name License Number Expiration Date: Tax ID Number Please check all forms of funding your facility receives: Head Start Early Head Start State Head Start State Pre-K Title I IDEA State Subsidies: Contracts State Subsidies: Vouchers For Head Start/Early Head Start or Multi-Site Programs Is this child care program owned or managed by another organization? Yes No If yes, give the parent company name/address: FOR ALL PROGRAMS Number of children served Center Auspice Profit Nonprofit Head Start Is your center accredited? Yes No If yes, by whom? 5 Associate 12/2014

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