Fillable Form 1: 1. Personal Information

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Form 1: 1. Personal Information

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  • 81 check-boxes
  • 139 other fields

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REV 2/14 Page 1
1. Personal Information
Please Print
Application Date: __________________________ Social Security #
1
: ______
Name:
First Middle Last
Address:
City: State: OH Zip: __ County: ______________
Home Phone #: ____________ Cell Phone #: ____ Fax # ________________
Gender: Female Male Date of Birth: _________________________________
E-mail: _______________________________________________
Are you a citizen of the United States? Yes No
1
(
1
If not a citizen or no SSN, please complete IRS form W-9)
How did you find out about the T.E.A.C.H. Early Childhood
®
Project? (check one)
Mailing My Center Director T.E.A.C.H. Recipient CCR&R Agency College
Website Presentation Workshop Other (please specify):____________
Family Structure: How many people live in your household? _______ Of these, how many are:
Your Parents?____ Siblings?_____ Spouse/Significant Other?_____ Children?______ Others?_______
Ethnicity:
Are you of Hispanic, Latino, or Spanish origin?
No Yes, Mexican, Mexican American Yes, Puerto Rican Yes, Cuban Yes, Other Hispanic, Latino or
Spanish
Do you consider yourself….?
White Black/African American American Indian or Alaska Native Asian Indian
Japanese Native Hawaiian Guamanian or Chamorro Korean
Chinese Vietnamese Samoan
Filipino Other Pacific Islanders:__________________ Other Asian:______________________
Other race:______________________
The above information is used for demographic purposes only
Child Development Associate
(CDA)
Assessment Fee Scholarship
Please make a copy of items, including
payments, for your records
REV 2/14 Page 2
How long have you worked in the early childhood education field?
Less than 2 Years 6-10 Years
2-5 Years 10+ Years
Please check the box that best describes your educational history:
No high school diploma Associate Degree (Major:____________________________) Doctorate
High school diploma/GED Bachelor Degree (Major:_____________________________)
1-year certificate Master Degree (Major:_______________________________)
Please check the box that best describes your educational goal:
Earn an Early Childhood or School-Age Credential
Take a few early childhood courses to obtain or upgrade job-related skills
Earn an Early Childhood, Infant/Toddler or School-Age Certificate
Earn an Early Childhood Associate Degree
Earn an Early Childhood Associate Degree and transfer to a four-year college/university to earn Bachelor’s Degree
Earn an Early Childhood Bachelor’s Degree
2. Education Information
The following four requirements, as outlined in the CDA Competency Standards book, must be
completed prior to submitting this application:
1) Have you completed 120 hours of education in 8 subject areas in the last 5 years? Yes No
2) Do you have at least 480 hours of professional experience within the past 3 years? Yes No
3) Have you completed the professional portfolio within the past 6 months? Yes No
4) Have you gathered family questionnaires within the past 6 months? Yes No
I intend to apply for the following type of CDA Credential (please choose one):
Center based infant/toddler (children up to 36 months of age)
Center based preschool (children agesS 3 to 5 years)
Family Child Care
Are you currently enrolled at a community college? Yes No
Is there a community college you would like to attend? ___________________________ Campus: _______________
3. Employment Status
Program License Number: Program Name:_______________________________________________
Start date of employment at your current program: ______
What is your current job title?
(check only one)
Teacher
Assistant Teacher
Administrator
Family Child Care Professional
Non-Teaching Professional Staff
Non-Teaching Support Staff
What age groups do you teach?
(please check all that apply)
Infants (0-12 Months)
Toddler (13-36 Months)
What is your current hourly wage?
How many hours per week ______ (0-60) and months per year _____ (0-12) do you work?
Average daily number of children in your classroom __
REV 2/14 Page 3
4. Professional Registry
Your OPIN Number (from the Ohio Professional Registry):__________________________
If you do not remember your OPIN, use this link to login to your registry account and view your OPIN:
https://login.occrra.org/
If you are not yet in the Registry, use this link for instructions to start using the Registry:
http://www.opdn.org/documents/RegistryBasicInstructions.pdf
Completing steps 1, 2 and 3 will let you view your OPIN on your Profile Summary page.
5. Additional Program Information
Director/Administrator/Owner Name: Title: __
Phone: ______________________ Cell: ________ Email: _____________________________
Program Address: __
City: ____ Zip: _ County: ________________
Program Phone: ______________________________ Program Fax:________________________________________
Program Email: __________________________________________________________________________________
Program Mailing Address, if Different Than Above:
Program Billing Address, if Different Than Above:
Street:
Street:
City: Zip Code:
City: Zip Code:
Phone: ( )
Phone ( )
Fax: ( )
Fax: ( )
Type of Program: Head Start For profit Not for profit
Step Up To Quality Rating: One Star Two Star Three Star Four Star Five Star Not SUTQ rated
Part-time Program? Yes No (check one) Hours per day children are in care?____________________
Is your program accredited? Yes No If yes, by whom?__________________________
# of children currently enrolled: ______ # of children on state subsidy: _________
Please check all forms of funding your facility receives (check all that apply):
Head Start State Pre-K Title I State Subsidies: Contracts
Early Head Start IDEA State Subsidies: Vouchers
# of full-time staff:_____ # of staff that work less than 12 months per year:______
# of part-time staff (work less than 40 hours per week):______
REV 2/14 Page 4
6. Statement and Signature of Applicant
I, __________________________________ (applicant’s name) attest that the information provided on this
application and the supporting documentation is true to the best of my knowledge. I understand that the social
security number provided is my correct tax identification number and I am a U.S. citizen. I understand that falsifying
application information or documentation or the failure to comply with documentation requirements may result in the
inability to be a participant in this program. If my participation is terminated due to my failure to comply with
documentation requirements, I understand that my employer may be notified along with the program funder. If for
any reason the scholarship money is issued incorrectly as a result of false information provided by me, I acknowledge
that I will be required to reimburse T.E.A.C.H. Early Childhood
OHIO for the monetary support that was received in
error. Based on this information, I am applying for a scholarship from T.E.A.C.H. Early Childhood
OHIO to help pay
the cost of early childhood education expenses.
Signature of Applicant Date
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REV 2/14 Page 5
7. Participation Agreement
Scholarship recipient agrees to:
Complete and submit the
T.E.A.C.H.
CDA Assessment Fee Application
Pay $50 of the Assessment Fee*
Submit verification of 120 hours of education in 8 subject areas to the OCCRRA office
(Education must have been obtained in the last 5 years)
Commit to continued employment at the sponsoring child care program, or to keep her Type B
Family Child Care Home open for six months after the date indicated on the CDA Credential
Send a copy of the CDA Credential to the OCCRRA office once received
Complete all requirements outlined in this agreement during the specified contract period
Skip the next section if you are a Type B Family Child Care professional or owner of a
licensed program and sign only as applicant below
The Sponsoring Child Care Program agrees to:
Allow observation of the scholarship recipient in the center by a representative of the Council for
Professional Recognition
The Sponsoring Child Care Program Representative agrees to:
(Choose one of the options below by checking the appropriate box)
OPTION 1: Pay $100 bonus award to the recipient after receipt of the CDA Credential
(OCCRRA will also pay a $100 bonus award to the recipient)
OPTION 2: Grant the recipient a 1% raise within 30 days after receipt of the CDA Credential
(OCCRRA will also pay a $100 bonus award to the recipient)
OPTION 3: Pay $100 of the assessment fee to OCCRRA (must be included with application
for this scholarship and made payable to OCCRRA*) OCCRRA will pay a $200 bonus award to
the recipient
*Payments received by OCCRRA will be refunded in the event the scholarship is not awarded. By signing below you
are indicating your agreement with all statements in this application and understand that a check or money order
(made out to OCCRRA) must accompany this application.
___________ _________
Signature of Applicant Date
_________________________ ________________
Signature of Program Director/Owner or Board Chairperson Title Date
______________
Print Name of Program
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REV 2/14 Page 6
T.E.A.C.H. Early Childhood® OHIO
Checklist of Attachments for the
CDA Assessment Fee Scholarship Application
In order to process your scholarship application, please send the following items to:
Ohio Child Care Resource and Referral Association
T.E.A.C.H. Early Childhood® OHIO
2760 Airport Drive, Suite 160
Columbus, OH 43219
Fax 614-396-5960
Email: teach@occrra.org
All Scholarship Applicants:
Completed and signed T.E.A.C.H. CDA Assessment Fee Scholarship Application
Proof of completion of 120 hours of professional education within the last 5 years
Copy of your program license
Check or money order for $50 to cover the applicant’s portion of the Assessment Fee (payable to OCCRRA)
Center Staff:
If Scholarship OPTION 3 (on page 5 tilted
Participation Agreement Page
) is chosen, the program must include
a $100 check or money order payable to OCCRRA
Verification of income: Copy of a current paycheck stub
Type A and Type B Family Child Care Professionals:
Verification of income:
- Schedule C form (from federal tax return)
OR
- A month of four consecutive weekly statements from your county portal which provides
the amount of payment and family copays
- Copies of private pay receipts from the same time period or signed statements from
families stating how much they pay for care
- If you participate in the Food Program, a copy of your most recent payment
Use this link to see what comes next in the application process:
http://teach.occrra.org/documents/whats_next.pdf
Please contact the T.E.A.C.H. office if you have any questions - 877-547-6978 (toll free); 614-396-5959;
614-396-5960 (fax); or email teach@occrra.org
04.12
Statement of Income for Type-B Professionals
Instructions: This sheet is to help you determine your monthly earnings and hourly rate from your family child care
home business. For each question, use the monthly amount you earned and expenses incurred. These must come from
the same month. Remember, you must include verification of y o
ur income such as c opies of receipts f or
each of the children you c
are for or a sig
ned statement from each parent with the amount paid each
week. You will also need
documentation for publicly subsidized children.
A. MONTHLY REVENUE
1. How much did you receive from private pay parents? $ ________________
2. How much was the Title XX/county/ODJFS subsidy for children in your care? $ ________________
3. How much did you receive in co-payments from subsidy parents? $ ________________
4. How much was your Child & Adult Care Food Program Reimbursement? $ ________________
Total $ Box 1
B. MONTHLY EXPENSES
How much did you spend on your home child care business last month for:
1. Food Expenses $ __________________ 5. Transportation $__________________
(use $0.25 per mile)
2. Toys $ __________________ 6. Training fees $__________________
3. Assistant/Substitute Care $ __________________ 7. Gifts for Children/Families $ __________
4. Crafts/Supplies $ __________________ 8. Other $__________________ Specify
Total $ Box 2
C. HOURS WORKED
In a typical week:
Day
EXAMPLE
Mon Tues Wed Thurs Fri Sat Sun
Time first
child arrives
7 am
Time last
child leaves
3 pm
Total hours
per day
8 hours
Sum your total hours worked per day to get your total hours worked per week and enter here Box 3.
We only count up to 60 hours worked per week when figuring a wage per hour. We multipy your total
hours worked per week (up to 60) by to get the answer in Box 4, hours per month.
D. ESTIMATE HOURLY WAGE
Box 1 - Box 2
= Box 5 wage per hour
Box 4 hours per month
0
0
1.00
4.33
0
0
$0.00
4.33
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Completed 2 June 2021

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