WELCOME! Thank you for your interest in a CDA Scholarship through Kansas Child Care Training Opportunities (KCCTO). In this application you will find: KCCTO CDA Application CDA Application Checklist Applicant Reference Form from Co-Professional Applicant Reference Form from Parent If you have any questions or comments, please feel free to give us a call or email us at 800-227-3578 or email us at: Sincerely, Haley Anderson CDA Resource Specialist 66502-2912 Ph.: 800.227.3578 or 785.532.7197 Page 1
KCCTO, Inc. CDA SCHOLARSHIP APPLICATION Applicant Information Applicant Last MI First Business Home Address Business Address (if different) Mailing Address (if different) Email Address County KDHE License Number Total # of children currently enrolled Education Completed: What is the highest level of education you have completed? (check one) GED High School 1 Year College/Vo-Tech 2 Year College 4 Year College Degree: Major: Minor: AMOUNT OF TIME WORKING WITH CHILDREN: (CDA requires 480 hours within last 3 years) Year/months and Location of facility or employer 66502-2912 Ph.: 800.227.3578 or 785.532.7197 Page 2
Additional Information Attach on a separate piece of paper 2-3 paragraphs for each bullet listed below. A written explanation of future professional development plans. A written statement describing your reason for requesting a CDA scholarship. References Select two individuals to serve as references. One should be a co-professional and one reference should be a parent of a child currently in your care. References should mail the Application Reference Form directly to the KCCTO office with an addressed envelope provided by the applicant. Please write your name where it says Applicant and the name of the person completing the references should be written where it says Reference. Eligibility Affirmations Must meet all eligibility requirements listed below Yes I am currently licensed and in good standing with KDHE. I do not currently hold a CDA. I am not receiving any other CDA financial assistance. I do not hold a college degree in Early Childhood or a related field. I have taken CDA 2.0 online through KCCTO. Agreements I agree to participate in studies and surveys conducted by KCCTO as a follow-up to this scholarship. I have not received, nor am I eligible to receive, funding support for CDA assessment fees from any other agency or organization. I agree to notify KCCTO regarding the date(s) for the Verification Visit by the Professional Development Specialist and the CDA Exam. Application Checklist A copy of your current KDHE license Proof of in-service training/college credit hours completed (120 hours) Professional development goals Reason for requesting a CDA scholarship Signature of Applicant I certify that the information given and attached to this Application is, to the best of my knowledge, correct. If awarded a Scholarship, I agree to prepare for and complete the CDA assessment process for a determined quarter or forfeit the scholarship and to provide post assessment information as requested. I certify that I meet guidelines set forth under KDHE regulation 65-516 regarding restrictions on persons maintaining or residing, working or volunteering at child care facilities (including, but not limited to criminal conviction or validated abuse allegations). I understand that all information released will be for the exclusive and confidential use of Kansas Child Care Training Opportunities, Inc. 66502-2912 Ph.: 800.227.3578 or 785.532.7197 Page 3
KCCTO, Inc. CDA Scholarship Applicant Reference Form This information will be kept confidential. Applicant: ( ) Reference: ( ) Co-Professional Reference What skills and experience does the applicant have in working with young children? Please comment on any knowledge of the applicant s work habits, personal and professional conduct as they relate to a career in early childhood education. Signature of Co-Professional Reference I certify that the information given and/or attached to the Reference Form is, to the best of my knowledge, correct. I understand that all information released will be for the exclusive and confidential use of Kansas Child Care Training Opportunities, Inc. Please mail form directly to KCCTO, Inc. within a sealed envelope provided by the Applicant. 66502-2912 Ph.: 800.227.3578 or 785.532.7197 Page 4
KCCTO, Inc. CDA Scholarship Applicant Reference Form This information will be kept confidential. Applicant: ( ) Reference: ( ) Parent Reference What skills and experience does the applicant have in working with young children? Please comment on any knowledge of the applicant s work habits, personal and professional conduct as they relate to a career in early childhood education. Signature of Parent Reference I certify that the information given and/or attached to the Reference Form is, to the best of my knowledge, correct. I understand that all information released will be for the exclusive and confidential use of Kansas Child Care Training Opportunities, Inc. Please mail form directly to KCCTO, Inc. within a sealed envelope provided by the Applicant. 66502-2912 Ph.: 800.227.3578 or 785.532.7197 Page 5