T.E.A.C.H. Early Childhood TEXAS CDA/CCP Assessment Fee Scholarship Application (updated 4/28/2014)

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1 CDA/CCP Assessment Fee Scholarship Application (updated 4/28/2014) Name Address City, State, Zip County Phone Number Home: Work: SSN Date of Birth (mm/dd/yyyy) Gender Date: Employment Status 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) Family Based Professional Non-Teaching Professional Staff Non-Teaching Support Staff Preschool (37 Months PreK) School Age 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 OFFICE USE ONLY Date Received Income Verification 1 st Approval Scholarship Type Database 2 nd Approval Training Hours Funding Ethnicity Page 1 of 10

2 CDA/CCP Assessment Fee Scholarship Application (updated 4/28/2014) 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, 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 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 Are you currently enrolled at a community college? Yes No When would you like your scholarship to begin? (circle one) FALL SPRING SUMMER (year) Page 2 of 10

3 CDA Assessment Scholarship Application Which of the following credentials and specializations do you currently hold? CDA: Infant/Toddler Specialization: Bi-Lingual CDA: Preschool (language: ) CDA: Family Child Care Home [State] Issued Credential CDA: Home Visitor Post BA (state teaching license) Educational Information Have you taken any college courses in the past two years? YES NO Have you taken any ECE credits in the past two years? YES how many? NO (enter zero into how many? ) High School Dates Attended Diploma G.E.D. Yes No Yes No College/ University Dates Attended Major Degree or Cred. Hrs Are you CPR/First Aid Certified? YES NO 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: Page 3 of 10

4 CDA/CCP Assessment Scholarship Application What is your preferred language for learning? Family Structure How many people live in your household? Has either of your parents or any of your brothers or sisters attended college? YES NO Number Relationship Parents Siblings Spouse/Significant Other Children Other Does either of your parents or any of your brothers or sisters have a college degree? YES NO What are your professional goals in early childhood education? Describe how a CDA will help you achieve these goals. Be sure to include your long term career goals. Is there anything you would like us to consider when reviewing your application? You may attach a separate paper with answers to questions if you choose. CDA Process Please check the following boxes if you have completed the components of the CDA process: Order your Competency Standard Book from The Council for Professional Recognition Family Questionnaires Resource File Completed 120 hours of training in the last 5 years (All training hours must be from someone listed in the Texas Trainer Registry or from an institute of higher education.) Found a Professional Development Specialist. Name: Number: Please Choose One Option Only (Options may be contingent on available funding)(ccp available fees will change based on CCP fee) For Center Based Programs Page 4 of 10

5 Option 1 Participant Agrees to: Pay 15% of the assessment fee ($63.75) Complete the assessment application from the CDA Council Submit assessment cover letter to TEXAS AEYC if awarded a scholarship Commit to remaining in the child care for 3 months after receiving the CDA Credential Notify TEXAS AEYC upon attainment of CDA Credential Center Agrees to: Allow observation of teacher in center by a representative from the Council for Early Childhood Professional Recognition Option 2 Participant agrees to: Complete the assessment application from the CDA Council Submit assessment cover letter to TEXAS AEYC if awarded a scholarship Notify TEXAS AEYC Upon Attainment of CDA Credential Commit to employment at sponsoring center for 6 months after receiving the CDA Credential Center agrees to: Pay 15% of the assessment fee ($63.75) Allow observation of teacher in center by a representative from the Council for Early Childhood Professional Recognition Option 3 Participant agrees to: Pay 7.5% of the assessment fee ($31.87) Complete the assessment application from the CDA Council Submit assessment cover letter to Texas AEYC If awarded a scholarship Notify TEXAS AEYC Upon Attainment of CDA Credential Commit to employment at sponsoring center for 6 months after receiving the CDA Credential Center Agrees to: Pay 7.5% of the assessment fee ($31.88) Allow observation of teacher in center by a representative from the Council for Early childhood Professional Recognition. Option 4 (For Family Child Care Home) Participant agrees to: Pay 15% of the assessment fee ($63.75) Complete the assessment application from the CDA Council Submit assessment cover letter to TEXAS AEYC if awarded a scholarship Notify TEXAS AEYC Upon Attainment of CDA Credential Commit to keeping registered Family Child Care Home in operation for 6 months after receiving the CDA Credential Option 5 (option may also be used for the CCP) Participant Agrees to: Complete the cover letter application from the CDA Council Commit to remaining in the child care for 6 months after receiving the CDA Credential Notify TEXAS AEYC upon attainment of CDA Credential Center Agrees to: Allow observation of teacher in center by a representative from the Council for Early Childhood Professional Recognition Pay 15% of the assessment fee ($63.75) Award a $150 bonus after 6 month commitment * Recipients will also be awarded a $150 bonus from T.E.A.C.H. upon earning their credential. (Participant s Signature and Date) (Center Director s Signature and Date) Please check all forms of funding your facility receives: Head Start Early Head Start Page 5 of 10

6 State Head Start State PreK Title I IDEA State Subsidies: Contracts State Subsidies: Vouchers Other Facility Information Center Name License Number License Type Circle One: Full Permit Initial Permit Registered Certified Address City, State, Zip County Phone Number Director/Owner Please fill this portion out to complete application. Failure to provide this information will delay review process. Center Auspice (check one): Profit Nonprofit Head Start Public Pre-K Military Faith-based Center Capacity Number of children currently enrolled: Total number of Workforce subsidized children served Total number of: Full-Time Staff Part-Time Staff Number of staff employed less than 12 months: Is your Center accredited: Yes No If yes, by whom? Is your Program a Texas Rising Star Program? NO 1 Star 2 Star 3 Star 4 Star 5 Star (Please include a copy of the contract showing subsidized children are accepted into the program.) (Signature of Chairperson/Owner/Director) Page 6 of 10

7 Statement of Income (Center-Based only) Instructions: List sources of income available to you. For each source of income, you must provide verification. A statement from your employer indicating your hours and rate of pay or a most recent pay stub will verify earning from a job. A statement from your ex-spouse or a court award letter can be used to verify child support. Family child care providers must first complete the Family Child Care Provider s Income Worksheet on the right and enter the monthly earnings as income below. Applicant s Income Employer Hours per week Earnings $ per $ per Employer Hours per week Earnings $ per Are you a student? yes no If yes, please complete lines a-c below. a. Scholarship/Grant b. Scholarship/Grant c. Student Loan Child Support/Alimony AFDC/SSI _ Applicant s Total Income $ per Applicant s Total Family Income (spouse or other family members included) $ per Family Child Care Provider s Income Worksheet Instructions: This sheet is to help you determine your monthly earnings from your family child care home. For each line, use the amount you made or spent last month. Remember, you must include verification of your income such as copies of receipts from each of the children you care for or a signed statement from each parent with the amount they pay you each week. Monthly Revenue 1. Total amount received from parents each week 2. Total Monthly Parent Fees (multiply line 1 x 4.33) 3. Amount of Child Care Food Program Reimbursement 4. Amount of Workforce or Child Care subsidy for children in your care 5. Total monthly revenue (add lines 2,3, & 4 above) Monthly Expenses Last Month, how much did you spend on the following items for children in your care? 6. Food 7. Toys 8. Assistant/Substitute Care 9. Crafts/Supplies 10. Transportation ($0.25 per mile) 11. Training Fees 12. Gifts for children/families 13. Other (Specify) 14. Total Monthly revenue (add lines 6-13 above) Monthly Revenue (Line 5) Monthly Expenses (Line 14) - Monthly Earnings = Page 7 of 10

8 Application Due to TEXAS AEYC: The Council for Professional Recognition accepts applications on a rolling basis. Once we receive your contract back signed along with your appropriate portion of CDA Assessment fee, you will be able to submit your assessment application to the Council with a T.E.A.C.H. voucher for payment for the $425 assessment fee, to the CDA Council. Once the Council receives your assessment application, they will notify you and you will have six months to complete your Professional Development Specialist visit and CDA Exam. If you do not complete your visit and exam within the six months, you will have to start the process again, with a second fee (TEACH will not cover this fee). Upon submitting this application to Texas AEYC, your application will be reviewed. If you are awarded a scholarship, you will be notified and sent a contract. Please allow us 4 weeks to process your application (The process for CCP credentials is very similar but does vary, please call for specific details) Which type of CDA are you applying for? Center-based infant/toddler program (children up to 36 months) Center-based preschool program (children 3-5 years) Family child care program (small or large child care home) Check here if you will apply for the Bilingual Specialization Applicants Signature Date THIS APPLICATION MUST BE ACCOMPANIED BY VERIFICATION OF INCOME. Applications may take 4-6 weeks to process. Once we receive your application, we will review for determination of eligibility. If you meet the criteria for a scholarship and funds are available, you will be sent a contract. YOU MUST RETURN THE SIGNED CONTRACT ALONG WITH YOUR CDA DIRECT ASSESSMENT APPLICATION AND ALL PARTIES PORTION OF ALL ASSESSMENT FEES. APPLICATION WILL NOT BE CONSIDERED COMPLETE UNTIL Signed Agreement, CDA Assessment Application and ALL PAYMENT(S) ARE RECEIVED. PLEASE DO NOT SEND PAYMENT OR CDA ASSESSMENT APPLICATION WITH THIS APPLICATION. Page 8 of 10

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10 Checklist for your application. Please make you re your application includes all of the following. Failure to send all documents and failure to sign will delay the process. Verification of Income (check stub) Participation Agreement (with two signatures) (Page 5-6) Copy of Contract from Center showing subsidized (CCMS) Children are accepted (please call with any questions about this document) Signed authorization to work form Copy of Photo ID & SSN card or Birth certificate (see I-9 for additional information) Training Certificate Showing Completion of 120 hours T.E.A.C.H. Application Completed and Signed (Page 5 and 8 from applicant) Family Child Care Monthly Income Worksheet (Family Child Care Only Page 7) Mail or Fax this Application with Verification of Income to: Texas AEYC P.O. Box 4997, Austin, TX FAX (866) If you have any questions, please call (512) TEACH@texasaeyc.org Page 10 of 10