Student Survey and
Program Intent Form
Early Childhood Education Program
Instructions – The following information will help us learn a little about your prior experience and your future
goals. Please read and answer each question. Then sign and date the form at the bottom.
I have been, or am currently, employed in an early childhood program (day care, preschool or other).
Yes No
The various program options listed below have been clearly explained to me. I understand that I am enrolling
in an Early Childhood Program at Indian Hills Community College which will prepare me to work in a child care,
preschool, Head Start, or as a Family Home Provider.
At this point in time, my goal is to complete the following level of education. . .
Twelve credit Child Development Associate (CDA)
One-year Child Care Technician Diploma
Day Format
Online Format
Combined Formats
Two-year Early Childhood Associate Degree
Day Format
Online Format
Combined Formats
I also have a long term goal of achieving a …
Four-year Early Childhood/Elementary Education w/ the Pre K/K Endorsement from
Buena Vista University.
Four-year Early Childhood/Elementary Education from Iowa Wesleyan College.
Four-year Early Childhood Degree from another college.
Four-year Elementary Education Degree from another college.
Name:
Signature: Date:
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signature
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