Rising STARS Tuition Assistance Program Application (Effective July 1, 2014)

PA Keys to Professional Development c/o BCIU P.O. Box 16050 Reading, PA 19612-6050 FAX: 610-987-8400 Rising STARS Tuition Assistance Program Application (Effective July 1, 2014) INSTRUCTIONS: Complete this application form and mail it with all required documentation to the PA Keys to Professional Development at the above address. Complete all information requested in the spaces provided. Please complete a separate application for each course. Applicants will be notified by mail of incomplete applications applications will not be considered for approval until they are complete. 1. APPLICANT INFORMATION *Applicant s Name: Vanore Lisa Helen (Please print or type) Last First Middle Maiden *Social Security #: xxx-x5-3214 (Required) *Email Address: lvanor@hotmail.com (Required) *Home Address: 1129 South Street York Springs PA 17372 Number Street Apt. # (if applicable) City State Zip Code *Daytime Phone #: ( 717 _) 116-5296 Evening Phone #: ( 717 ) 553-1289 2. EMPLOYMENT INFORMATION *I am a (must select one): Family Child Care Home Provider - MPI ID #: - Facility Name (From Registration Certificate): Group Child Care Home Employee - MPI ID #: - Facility Name (From Certificate of Compliance): Yelena Test X Child Care Center Employee - MPI ID #: 3 0 0 4 0 8 2 9 7-0 0 0 2 Facility Name (From Certificate of Compliance): Head Start Employee Grant ID #: Grantee Name: Effective July 1, 2014, all providers regardless of type must be employed at a Keystone STARS Facility. *My Facility is currently a Keystone STARS level: STAR 1 X STAR 2 STAR 3 STAR 4 *My Facility is located in the following Regional Key: Northeast Northwest X South Central Southeast *I work 30 hours per week at the facility noted above. Southwest *I have been employed in an early learning program operated by this legal entity for 3 years and months. *I work in a school-age program. Yes X No *I work in an infant or toddler classroom (Birth to 3 rd Birthday). _X Yes No *Early Childhood Education teacher certification is required for my position. Yes X No *PA Director Credential is required for my position. Yes X No July 1, 2014 Page 1

3. DEGREE/CERTIFICATE INFORMATION This course is part of a: X Child Development Associate (CDA) program PA Director Credential Series PA School-Age Credential Series Associate Degree Program Name of Degree: Early Childhood Education Bachelor Degree Program Name of Degree: Master Degree Program Name of Degree: PA Early Childhood Education Teacher Certification Program (PreK-4) *AND/OR I am taking this course in order to advance my Career Lattice Level. Yes X No If yes, please indicate course level: Associate Bachelor s Master s *My degree/certificate program includes a total of 60 credits. OR *My development plan requires credits for advancement on the career lattice OR *I need to complete credits in order to obtain my PA PreK-4 Teacher Certification. *I have completed 3 credits toward my degree/credential/certification. *My expected month and year of graduation, or of credential/certification receipt is 05 / 17. OR mm yy *My expected month and year of completion of credits for advancement on the career lattice is /. mm yy 4. COURSE INFORMATION *Course Number: EARL 106 *Course Title: Early Childhood Development and Learning *Name of Institution of Higher Learning: Northampton Community College *Accrediting body: Middle States Commission on Higher Education (You can search for accreditation information at http://ope.ed.gov/accreditation/, or at http://www.detc.org/search_schools.php for distance learning institutions). *Date course begins: 0 9 /08/14 *Date course ends: 12/ 12/ 14 *# of credits: 1 2 3 4 5 6 (Circle one) *Total tuition amount for this course: $ 528.00 (Do NOT include books, fees, other miscellaneous costs) *Tuition for this course is funded/partially funded by another source. Yes X No (Do not include Pell Grants) *If yes, indicate the amount of funding: $, and name of agency/organization that is providing the funding: *This is the first course that I am taking toward this degree/certificate. Yes X No If no, please indicate your current Grade Point Average (GPA): 4.0 July 1, 2014 Page 2

5. REQUIRED DOCUMENTATION Please initial in blue ink on the line next to each item that is included with this application. X PA State Family Day Care Home Certificate of Registration (Family Child Care Homes) OR PA State Certificate of Compliance (Group Child Care Homes and Child Care Centers) X Keystone STARS Certificate PA Teacher Certification (If coursework is being taken to support movement to Level 2 certification) *Documentation from the institution of higher learning: X Course Title X Course Description (A short paragraph listing course number, title, and giving a synopsis of what will be taught in the course; may be photocopied from a hard copy course catalogue or printed from an online catalogue). X Dates of Course X Number of credits X Itemized Financial Billing Statement showing the cost of tuition for the course. The Billing Statement must indicate that the applicant has been registered for the course, and must state the course name and the tuition cost for that specific course. Fees or other costs should not be included in the tuition cost line. X Transcript showing current GPA as of most recent completed semester. Office transcript with raised seal not required. (Not required only if this is the first course taken for this degree/certificate) *Payment is to be made (must select one of the following): Directly to the applicant (Financial Statement from institution of higher education showing proof of payment must be included) To the employer, payable to employer mailing address (Financial Statement from institution of higher education showing proof of payment must be included) X To the institution of higher education via the applicant, please list your student ID_N-65107524 (Complete application and all required documents must be received a minimum of four weeks prior to the course start date). 6. APPLICANT ATTESTATIONS and AGREEMENTS - Please initial in blue ink on the line next to each statement; do not mark with a check mark or an x. Items (a) through (e) and either item (f) or item (g) must be initialed in order for application to be considered complete. LHV (a) I attest that I have been employed by Yelena Test since 07 / 11. (Legal entity name) (mm / yy) LHV (b) I attest that I work at least 20 hours per week at the above-named early learning program. LHV (c) I understand that in accepting Rising STARS Tuition Assistance Program funds, I am agreeing to maintain my employment at my current legal entity or another Keystone STARS early learning program for two (2) months for each credit paid, with the two months beginning at the conclusion of the course for which Rising STARS Tuition Assistance was received. Total time due will not exceed 24 months following the conclusion of the most recent course completed. If I do not meet this requirement, I will reimburse the Rising STARS Tuition Assistance Program funds paid on my behalf for which I did not maintain the employment requirement. LHV (d) I understand that if I fail to maintain a grade point average (GPA) of 3.0 ( B ) or higher, I will not be eligible for the Rising STARS Tuition Assistance program for future classes until my GPA returns to a 3.0 or higher. LHV (e) I understand that should I drop out of, not complete the above class, or be unable to fulfill the required time owed per credit approved by the Program, I am agreeing to reimburse the Rising STARS Tuition Assistance. Program the amount of tuition paid on my behalf for this class. July 1, 2014 Page 3

LHV (f) I attest that my hourly wage is less than $20.00/hour. (Assistant Teachers, Aides, Teachers, & Assistant Directors) OR (g) I attest that my hourly wage is less than $25.00/hour. (Child Care Center Directors; Family or Group Child Care Home Owner/Operators; Head Start Education Managers, Coordinators, Site Supervisors) 7. EMPLOYER ATTESTATIONS Program Director or Owner must initial in blue ink on the line next to each attestation. Items (a) and (b) and either item (c) or item (d) must be initialed in order for application to be considered complete.. Do not mark with a checkmark or an x. VCB (a) I attest that the applicant has been employed by Yelena Test since 07 / 11. (Legal entity name) (mm / yy) VCB (b) I attest that the applicant works at least 20 hours per week at the above-named early learning program. VCB (c) I attest that the applicant s hourly wage is less than $20.00/hour (Assistant Teachers, Aides, Teachers, & Assistant Directors) OR (d) I attest that the applicant s hourly wage is less than $25.00/hour (Child Care Center Directors; Family or Group Child Care Home Owner/Operators; Head Start Education Managers, Coordinators, Site Supervisors). Virginia Bell 07/01/2014 Director/Owner Signature MUST BE SIGNED IN BLUE INK Date Virginia Bell Director/Owner Print Name Director Title 8. RELEASE OF INFORMATION and ATTESTATION OF ACCURACY STATEMENT *I _Lisa Helen Vanore give my consent for The Rising STARS Tuition Assistance Program to disclose any information included in this Rising STARS Tuition Assistance application to my Institution of Higher Education and my employer (Identified in section 7 of this application). The disclosure period for the exchange of information under this Agreement is one (1) year after the last date of signature to this Agreement. I certify that the information on and enclosed with this application is true and correct to the best of my knowledge. Lisa H Vanore 07/01/2014 Applicant s Signature MUST BE SIGNED IN BLUE INK Date Lisa Helen Vanore Printed Name of Applicant *All items marked with an asterisk must be completed. July 1, 2014 Page 4

COMMON WEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE CERTIFICATE OF COMPLIANCE This Certificate is hereby granted to To operate Located at Test YELENA TEST 555 camp hill, camp hill, PA 17011 LEGAL ENTITY NAME OF FACILITY OR AGENCY COMPLETE ADDRESS OF FACILITY OR AGENCY ADDRESS OF SATELLITE SITE ADDRESS OF SATELLITE SITE To provide test The total number of persons which may be cared for at one time may not exceed the Certificate of Occupancy, whichever is smaller. ADDRESS OF SATELLITE SITE TYPE OF SERVICES TO BE PROVIDED 10 MAXIMUM CAPACITY or the maximum capacity permitted by Restrictions: test This Certificate is granted in accordance with the Public Welfare Code of 1967, P.L.31, as amended, and Regulations 55 Pa. Code Chapter 3270 MANUAL NUMBER AND TITLE OF REGULATIONS and shall remain in effect from 1/4/2014 until 1/3/2015 unless sooner revoked for non-compliance with applicable laws and regulations. Certification ID: CER-00025889 MPI ID: 300408297-0002 dated September 22, 2008 NOTE: This Certificate is issued for the above site(s) only and is not transferable and should be posted in a conspicuous place in the facility. DEPUTY SECRETARY

STARS Certificate This is to designate that Yelena Test has earned a quality rating as a facility that is committed to maintaining compliance with program regulations and to enhancing quality early learning through Keystone STARS. 555 Camp Hill Expires: 01/03/2015 Thomas W. Corbett, Governor Commonwealth of Pennsylvania South Central Regional Key PO Box 2675, Harrisburg, PA 17105, www.pakeys.org

Early Childhood Education (EARL) EARL 106 Early Childhood Development and Learning (Cr3) (3:0) Students learn child development theories and milestones from prenatal to age 9 in the context of cultural and developmental variations. They learn inclusive teaching skills and strategies for all children including English Language Learners (ELL). They will understand the value of developing respectful, reciprocal relationships with families and community partners is a foundational skill. Students will be introduced to Art is a Way of Learning (AWL) as a curriculum framework. The course requires five observational visits to a variety of educational settings: infant/toddler, Preschool/Head Start program, 1st/2nd grade, 3rd/4th grade, and special education classroom. Observation visits total ten hours (two hours each). Also available through Online Learning. Child Abuse Registry, Criminal Background Check, and FBI clearances are required. Printed: 11/25/2013

Bill Vanor, Lisa H. Page I of I Northampton Community College Tuition Bill Vanore, Lisa H. Tuition Bill Options Program Session Year CRED FL 2014 lvanor@hotmail.com [ Set Options Fall 2014 08:52 06/25/2014 Name Lisa H. Vanore Address 1129 S o uth Str e et York Springs 17372 ID No N-65107524 Vehicle Res Hall Plate# Permit UNITED STATES Home Phone 717-116-5296 Major Early Childhood Ed Att Hrs 3.0 Advisor Number per Room Meal Plan Class Transfer Student Intend Major Early Childhood Ed Aud Hrs 0.0 Crs Sec Su Hrs Title Days Meeting Time t.ijeetmg Place Begin Date End Date EARL106 WA 3.0 ECE Dev and Learning TBA DIST WEB 000 09/08/14 12/12/14 Total Hours 3.0 Charges Assessed Financial Aid Applied Pending Tuition Res 2 528.00 Federal Pell Grant 0.0.00 0.00 Capital Fee Res 2 100.00 Comprehensive Fee 125.00 Technology Fee 50.00 Totals 803.00 0.00 0.00 Other Balance Charges Assessed Fin Aid Applied Payments/Credits Cash Refunds Computed Balance 0.00 + 803.00-0.00-0.00-0.00 = 803.00 Payment Options Northampton Community College Pay By Credit card Apply Online For A Payment Plan FALL 2014 Payment Plan - 20% or 1/S Due mhtml:file://c:\usersllorshi\appdata\local\microsoft\ Windows\Temporary Internet File... 06/25/2014

Final Grades Page 1 of 1 Final Grades N-65107524 Lisa H. Vanore Spring 2014 May 10, 2014 02:27 pm z Final grades for Spring 2014 are scheduled to be available to students by: May 5, 2014. z Your GPA and academic standing will also be updated by the end of the day on the dates above. z If you have a question about your grade, please contact your instructor. Student Information Current Program Associate in Arts Level: Credit Program: Early Childhood Education - AA Admit Term: Spring 2014 Admit Type: Student Catalog Term: Spring 2014 College: Acad Affairs Enrollment Mgmt Major and Department: Early Childhood Education, Education Department Academic Standing: Good Standing Credit Course work CRN Subject Course Section Course Title 21163 EARL 101 102 Arts in ECE Final Grade Attempted Earned GPA Hours Quality Points A 4.000 4.000 4.000 16.00 Credit Summary Attempted Earned GPA Hours Quality Points GPA Current Term: 4.000 4.000 4.000 16.00 4.00 Cumulative: 4.000 4.000 4.000 16.00 4.00 Transfer: 0.000 15.000 0.000 0.00 0.00 Overall: 4.000 19.000 4.000 16.00 4.00 RELEASE: 8.4 https://banner.edu/ban8/bwskogrd.p_viewgrde?term_in=201420 05/10/2014

Northwest Region Armstrong Beaver Blair Butler Cambria Camerson Centre Clarion Clearfield Clinton Crawford Elk Erie Forest Indiana Jefferson Lawrence McKean Mercer Potter Venango Warren Appendix A Southwest Region Allegheny Bedford Fayette Greene Somerset Washington Westmoreland South Central Region Adams Chester Cumberland Dauphin Franklin Fulton Huntingdon Juniata Lancaster Lebanon Mifflin Montour Northumberland Perry Snyder Union York Northeast Region Berks Bradford Bucks Carbon Columbia Lackawanna Lehigh Luzerne Lycoming Monroe Northampton Pike Schuylkill Sullivan Susquehanna Tioga Wayne Wyoming Southeast Region Delaware Montgomery Philadelphia