MARYLAND STATE DEPARTMENT OF EDUCATION
DIVISION OF EARLY CHILDHOOD DEVELOPMENT OFFICE OF CHILD CARE
200 West Baltimore Street, 10
TH
Floor, Baltimore, Maryland 21201
CHILD CARE CAREER AND PROFESSIONAL DEVELOPMENT FUND
INSTRUCTIONS: Complete this application form and mail it with all documentation to the Office of Child Care (OCC) at the
above address. Complete all information in the spaces provided. All applications must be accompanied by required
documentation. Incomplete applications will not be processed.
Applicant’s Name:
___________________________________________________________________________
(Please print or type) Last First Middle Maiden
Social Security #:___________________________________ Date of Birth (mo/day/yr):_______________________
Mailing Address: ___________________________________________________________________________
Number Street Apt. # (if applicable) City State Zip Code
Daytime Phone #:_______________________________ Alternate Phone #:______________________________
E-mail: ______________________________________________________
I am a: (Check the appropriate box.)
I am a Family Child Care Provider, registration #:____________________(attach copy of current registration)
I work in a Child Care Center: Position:____________________________________Age Group(s):___________
Center Name_________________________________________________, License #:_______
Address_______________________________________________________________________________
Number Street City State Zip Code
Name of CCCPDF Participating College:________________________________________________________________
Type of Degree: Associate Bachelor Course of Study/Major:_________________________________________
Enrollment: Month ______________________Year__________ Projected graduation: Month __________________Year________
Employment in child care – at least
one year of child care experience
AND work at least 10 hours per
• Family child care providers - A copy of current registration certificate.
• Child care center employees – Signed letter from current employer indicating,
hire date, position, number of hours per week and age group.
Maryland Child Care Credential at
Level Two or higher.
• Copy of current Maryland Child Care Credential certificate.
College enrollment toward a degree
in early childhood education or
related field
• Letter or other documentation of acceptance from a participating college
located in Maryland
• Professional development plan – list of courses and timeline required for
degree completion.
• A copy of CURRENT college transcript for courses completed (Continuation
STATEMENTS AND ASSURANCES: Initial each item to indicate that you understand and agree with each statement.
• I affirm that all information on this application and all attached documentation is true and correct. (____)
• I understand that giving a false statement will result in the denial of this application and recoupment of any funds distributed
as a result of this application. (_____)
• I understand that if I have had a child care license or registration suspended or revoked I may not be eligible to receive an
award through the fund. (____)
• I understand that if I am awarded funding through this program, I am required to:
o Successfully complete each college course and maintain a minimum of a 2.50 GPA, (____)
o Continue employment in the child care field at least 10 hours per week while completing college coursework toward a
degree, (____) and
o Upon the completion of college coursework and the degree, continue employment in the child care field at least 10 hours
per week, in Maryland, based on the requirements pursuant to COMAR 13A.14.09. (____)
• I have attached all required information. (____)
Signature:_______________________________________________ Date:_________________________
OCC-CCCPDF MARCH 2015 Keep a copy of the completed application and all documentation for your files.
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