Fillable FinancialSupportTuitionAssistanceCurrent - TECTA Student Information Form

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FinancialSupportTuitionAssistanceCurrent - TECTA Student Information Form

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The TECTA program is funded through a contract with the Tennessee
Department of Human Services and Tennessee State University,
Center of Excellence for Learning Sciences.
Revised 4/2017
Center of Excellence for Learning Sciences w Tennessee State University
TECTA Student Information Form
TECTA Orientation Location or Institution Attending ________________________________________________________
Social Security Number _____ - _____ - _______
Name ________________________________ ________________________ _____________________
Last First Middle
Employment Status
Your Place of Employment _______________________________________________________________________________
Ages of children in classroom (choose one)
o Birth to 8 months o 9 to 17 months o 18 to 36 months o 3 to 5 year olds
o School-Age o Family Childcare
o Mixed-age Group: Infants o Mixed-age Group: Infants and Preschool o Not a Direct Care Provider
TECTA Support Received for: Semester ___________ Year ____________
Salary: Please note: this question is for research purposes ONLY. Individual responses will not be identified or published.
$ ____________ per Hour
Current Position Title: o Asst. Director o Asst. Director/Teacher o Caregiver/Teacher
o DHS Staff o Director o Director/Teacher o Home Visitor
o Home Visitor Supervisor o Other o Owner of Program o Sub/Floater
o Teacher Aide o Authorized o Volunteer
Number of years in current position ________ Number of years in Early Childhood Field _______
Number of years at current place of employment _______ Hours worked per week_____________
Do you have children with diagnosed delays or disabilities in your classroom? o Yes o No
Number of children in your classroom____________
Please complete the reverse side if you are a first-time TECTA-supported student.
The TECTA program is funded through a contract with the Tennessee
Department of Human Services and Tennessee State University,
Center of Excellence for Learning Sciences.
Revised 4/2017
Center of Excellence for Learning Sciences w Tennessee State University
TECTA Student Information Form
Complete this side if this is the first time you are receiving TECTA services.
Please check the professional organization(s) to which you belong:
o Head Start Association o National Association for the Education of Young Children
o National Black Child Development Institute o National Child Care Association
o National Family Child Care Association o Tennessee Association for the Education of Young Children
o Tennessee Family Child Care Alliance o Tennessee School-Age Care Alliance
Highest education level completed before seeking TECTA support
o Less than 9th grade o 9th – 12th grade (no diploma) o High School Graduate/GED
o Some College o Technical Certificate o Associate of Applied Science
o Associate Degree o Bachelors/Baccalaureate Degree o Masters/Doctorate Degree
College or University of Highest Degree ________________________________________________________
Major: o Early Childhood Education o Elementary Education o Special Education
o Other ____________________ Graduation Date of Highest Degree ______/_________
Parents’ Educational Levels
Mother
o Less than 9th grade o 9th – 12th grade (no diploma) o High School Graduate/GED
o Some College o Technical Certificate o Associate of Applied Science
o Associate Degree o Bachelors/Baccalaureate Degree o Masters/Doctorate Degree
Father
o Less than 9th grade o 9th – 12th grade (no diploma) o High School Graduate/GED
o Some College o Technical Certificate o Associate of Applied Science
o Associate Degree o Bachelors/Baccalaureate Degree o Masters/Doctorate Degree
Professional Objectives
Why do you want to participate in TECTA training? (Check all that apply):
o Further my education o Help with my job search o Improve my job skills o Obtain a CDA
o Obtain a raise/higher pay
Have you completed other early childhood training during the last 12 months? o Yes o No
Did your employer require the training? o Yes o No
Do you plan to continue working in child care? o Yes o No
If no, please tell us why_________________________________________________________________________________
NOTICE: If you have changed your name and/or address since you last enrolled in a TECTA-supported course, please fill out a
TECTA Student Change of Information Form and return it as soon as possible to your local TECTA site.
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FinancialSupportTuitionAssistanceCurrent - TECTA Student Information Form

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Completed 19 November 2019

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