Fillable 2019 2020 ECE PDP Srvc Req Fillable (Diablo Valley College)

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2019 2020 ECE PDP Srvc Req Fillable (Diablo Valley College)

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This Early Childhood Education Department project is funded by
Page 1 of 4
ECE Professional Development Program
ECE PDP Service Request Packet
Academic Year 2019- 2020
Are you currently UemployedU in a Contra Costa County licensed Early Care and
Education program for children 0-5 years, at least 15 hours weekly?
If so, you can apply to receive the following benefits and services:
Educational Advising ECE-ESL-GE Study Groups
Child Development Permit Assistance Partial Tuition Reimbursement Information
Textbook Loans Lost Wages Information for ECE 250
Info about Education Stipends Professional Growth Opportunities
- Employees working in First 5 target zip code programs have priority for services -
Steps to become a PDP Participant
UINSTRUCTIONS
STEP 1: Fill out this ECE PDP Service Request Packet, which includes:
Academic Support Services Application
(requires your Employer’s signature)
PDP Service Request Form
STEP 2: Attach your Class Registration Confirmation for Summer or Fall ‘19
U
If you are a UnewU participant, attach all of your college transcripts
(Copies of unofficial transcripts are accepted)
You must have an Educational Plan on file in our office
(You will be
contacted to schedule an appointment if you do not have an educational plan)
Submit your forms and attachments by mail, fax, email or in person to:
30TU U30T 30T 30T
ECE PDP Office, Early Childhood South Building, Offices 201 & 202
Diablo Valley College, 321 Golf Club Rd. Pleasant Hill, CA 94523
Call: 925-969-2392 or 2393 Fax: 925-691-6031 or
Email: shandy@dvc.edu or DVCECEPDP@dvc.edu
DVC ECE Certificates:
Associate Teacher
Basic Teacher
Teacher
Master Teacher /Site Supervisor
DVC ECE Degrees:
AS in ECE
AS in ECE for Transfer
Other (Please list):
_____________________
Child Development Permits:
Associate
Teacher
Master Teacher
Site Supervisor / Program Director
Renewal for:
Page 2 of 4
Remember to ATTACH a Print out of
your DVC Class Schedule registration
ECE Professional Development Program
Academic Support Services Application
Fall 2019
Text Loans - Tutoring - Study Groups - Lost Wages
Name: _______________________________ ____________________________ DVC ID#: ________________________
Last, First
Contact Phone: _________________________________ Email: ______________________________________________
Emp
loyer: ________________________________________ City: __________________________ Zip: _______________
Start Date: ______________Position:______________________________ Work Schedule: ________________________
EMPLOYER’S SIGNATURE________________________________________ Phone: _______________________________
This form cannot be accepted without an employer’s signature. Working 15 hrs weekly in a licensed program with 0-5 yrs is required
ACADEMIC SUPPORT SERVICES
What is your current educational goal? (please check the appropriate box(es))
I would like to request the following academic support resources:
☐ Textbook Support ONLY for the attached approved courses to meet my Educational goal.
☐ Course/Section: __________________________________
☐ Course/Section: __________________________________
☐ Tutoring support on Wednesday Nights
☐ Application information about “Lost Wages” for ECE 250 - Practicum Lab (only if working at a QRIS Site)
Requests must be received AT LEAST two weeks prior to the first day of instruction. Applications are prioritized based
on employment location, educational goals, and date of receipt. All previously loaned texts must be returned in order to
receive services.
Please INITIAL and sign:
I understand that my application will be delayed or unable to be processed if I do not attach a DVC
Class Registration and fill out all the items in the Participant Enrollment Packet completely.
I
understand that a signed tutoring contract/text loan agreement is required to receive support.
STUDENT SIGNATURE: __________________________________________________________ Date: ________________
Return to:
Sue Handy or Mariana Rios, ECE PDP Office, ECS 201 & 202
DIABLO VALLEY COLLEGE 321 Golf Club Rd. Pleasant Hill, CA
94523
F
ax: 925-691-6031 or Call: 925-969-2392 or 2393 Email:
30Tshandy@dvc.edu30T or 30T 30TDVCECEPDP@dvc.edu
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Education Plan / Transcript Review
Certificate/Degree Information
Academic Support Services
Child Development Permit Assistance
Education Stipend Information
Page 3 of 4
continued
ECE Professional Development Program
1. Please tell us about yourself
2. Education
What is your highest level of Education?
Less than High School Diploma/GED or High School Diploma/GED from _____________________________
Some College Courses; College: ___________________________________________ Country: _________________
Associate’s Degree; Major:____________________ College: ____________________ Country: _________________
Bachelor’s Degree; Major: _____________________ College: ____________________ Country: _________________
Master’s Degree; Major: ______________________ College: ____________________ Country: _________________
If your Degree is from a Country other than U.S., do you have a Foreign
Transcript Evaluation? Yes No
If yes, please list the Evaluation Agency Name:_______________________
How many Early Childhood Education or
Child Development Units do you have?
________________
Do you have a CA Child Development Permit? Yes No Not Sure
If yes, select your current Level of CA Child Development Permit:
Assistant Teacher Site Supervisor
Assistant Teacher Master Teacher Program Director
Permit Expiration Date: Have you recently applied for a new permit or permit upgrade? No
__________________ Yes: Permit Level: ____________________ Date applied ____________
Please let us
know your educational and career goals: _____________________________________
_____________________________________________________________________
_____________________________________________________________________
DVC Student ID
Available Date and Times for Appointments:
Last Name
First Name
Middle Initial
(if applicable)
Previous Last Name
(if applicable)
Gender:
Male Female Decline to State
Date of Birth: ____ / ____ /________
Month Day Year
Mailing Address
City
State
Zip
Phone Number
Cell
( _______) _______ -____________ Home
E-mail Address
2019-2020 PDP Ser
vice Request Form
Requested Services at Intake (Please check all that apply):
(Examples: Achievement Certificate, AST Degree, AS degree, Apply for a Permit,
Become a Assistant Teacher/ Teacher)
Page 4 of 4
3. Employment
Facility/Program Name
Director/Owner First & Last Name
Facility/Program Address
City, State
Zip
Facility/Program Phone Number
( _______) _______ -____________
Facility License Number (Optional)
Start Date at this Work:
______/__________ (Month/Year)
How many hours do you work per
week?
_______________________
What is your income from ECE employment?
(check only one)
per hour per month per year $________
When did you start working in the ECE/CD field? _____________/______________ (Month/Year)
What is your position? (Select ONE)
Aide Associate Teacher Master/Lead Teacher Volunteer Family Child Care Owner
Assistant Teacher Teacher Site Supervisor Substitute Program Director
What kind of program do you work for? (Select ONE) State Preschool Program
Child Care Center/Program Head Start/ Early Head Start Program School-Age Program
..
Family Child Care License-Exempt Program Other: _______________________
What age group(s) of children do you work with? (Select all that apply.)
Infant (Birth to 17 Months) Pre-K (36 Months to Kindergarten Entry)
Toddler (18 to 35 Months) Kindergarten and School-Age
What languages do you use to communicate with the children and/or parents at your current work?
Arabic Cantonese Farsi Hmong Korean Punjabi
Sign
Language
Vietnamese
Armenian English
Filipino
Pilipino/Tagalog
Japanese Mandarin Russian Spanish Other
How do you identify your Race/Ethnicity?
American Indian or Alaska Native Hispanic or Latino White
Asian Middle Eastern Other
Black or African American Native Hawaiian/Other Pacific Islander Decline to State
B
y signing this document I am certifying all of the information provided herein is true and correct
We (Community Colleges PDP staff) enter information from this and other PDP forms, as well as student academic records, into
a PDP database and use this information to help advise you on your educational progress. Further, information is shared from
the database with the three Contras Costa Community Colleges, First 5 Contra Costa, and its designated evaluators within the
limits of FERPA (Family Educational Rights and Privacy Act) for the sole purposes of aggregate program evaluation and stipend
issuance. Your individual information will not be accessed for any other purposes, or given to any other entity.
I
understand and agree to the statement above. _________________________________________ _________________
Signature Date
We periodically invite select PDP participants to attend a focus group, complete an on-line survey, or agree to be called by First 5
Contra Costa evaluators and asked to participate in a telephone interview. Please help us learn how to improve the Professional
Development Program by authorizing the evaluators to contact you about these evaluation activities.
I
consent to be contacted to request
my participation in future evaluation activities. ____________________________________________ _______________
Signature Date
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Completed 22 July 2020

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