Name. Address. City, State, Zip County Phone Number Home: Work: SSN Date of Birth (mm/dd/yyyy) Gender. Employment Status

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1 Name Address City, State, Zip County Phone Number Home: Work: SSN Date of Birth (mm/dd/yyyy) Gender Date: Employment Status Name of Center, FCC or LFCC Address Center, FCC or LFCC Phone Number Center, FCC or LFCC Address Center, FCC or LFCC License Number License Expiration Date Please attach a copy of the current license with the application Does your facility serve families eligible for Purchase of Care (POC)? No If yes, what percentage of children are under POC? Does your facility care for children of military families? No If yes, Active Duty Guard Reserve (Check all that apply) What is your current job title? What age groups do you teach? (please check all that apply) Teacher Assistant Teacher Administrator Infants (0-12 Months) Toddler (13-36 Months) How many children are in your classroom or child care home? If you are an Administrator/owner, what is the center s enrollment to date? 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? Family Based Professional Non-Teaching Professional Staff Non-Teaching Support Staff Preschool (37 Months PreK) School Age

2 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? No Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Other Hispanic, Latino or Spanish Do you consider yourself.? White Black or African Am. 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 Mailing CCR&R Agency College My Center Director T.E.A.C.H. Recipient Workshop Website Other (please specify): Please check the box that best describes your educational history: No high school diploma Associate Degree High school diploma/ged (Major: ) 1-year certificate Bachelor Degree (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

3 Which of the following credentials and specializations do you currently hold? CDA: Infant/Toddler [State] Issued Credential CDA: Preschool Post BA (state teaching license) CDA: Family Child Care Home Have you taken any college courses in the past two years? Have you taken any ECE credits in the past two years? how many? (enter zero into how many? ) Are you CPR/First Aid Certified? Which languages can you speak fluently? Arabic Japanese Armenian Korean Chinese Lao Creole Persian English Polish French Portuguese Greek Russian Hindi Spanish Swahili Tagalog Thai Tribal: Urdu Vietnamese Yiddish Other: What is your preferred language for learning? Family Structure How many people live in your household? Have either of your parents or any of your brothers or sisters attended college? Number Relationship Parents Siblings Spouse/Significant Other Children Other Do either of your parents or any of your brothers or sisters have a college degree?

4 Are you currently enrolled at a college? Yes No When would you like your scholarship to begin? (circle one) FALL SPRING SUMMER (year) Which College would you like to attend? (circle one) Springfield College Wilmington University Delaware State University What are your professional goals in early childhood education? Describe how a Bachelor s Degree will help you achieve these goals. Be sure to include your long-term career goals. We may not be able to fund all applicants. Why should T.E.A.C.H. Early Childhood Delaware fund you over other applicants?

5 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)? 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 [AGENCY NAME] 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 Return completed application and statement of income to: T.E.A.C.H. Early Childhood Delaware 2004 Foulk Road, Suite 6 Wilmington, DE Or fax to Or to

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