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StudentInfoForm2016 Student Information Form

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Center of Excellence for Learning Sciences Revised 12/16/2013
Tennessee State University
TSU-TECTA Form: TECTA Student Information
Tennessee Early Childhood Training Alliance (TECTA)
Student Information Form
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PLEASE PRINT CLEARLY. Semester ________Year _______________________
TECTA Orientation Location or Institution Attending ___________________________________________________
Social Security Number: _________________-________________-_________________
Name: Last_____________________________ First ________________________ Middle ______________
Employment History
Ages of children in classroom (choose one)
Birth to 8 months 9 to 17 months 18 to 36months Ages3 – 5 Sc
hool Age
Mixed Age G
roup Infants Mixed age group Infant & Preschool Family Childcare
Please note this question is for research purposes ONLY. Individual responses will not be identified and published.
Salary $ __________ per Hour day week bi-weekly month year
Current Position Title: Asst. Director Asst. Director/Teacher Caregiver/Teacher Director
Director/Teacher Other Owner of Program Sub/Floater
Asst. Teacher Volunteer
Number of years in current position ________ Number years in Early Childhood Field ______.
Number of years at current place of employment: _______ Hrs worked per week:_____________
Do you have children with diagnosed delays or disabilities in your classroom? yes No
Number of Children in classroom____________
Please check the professional organization(s) to which you belong:
Head Start Association
National Association for the Education of Young Children
National Black Child Development Institute
National Child Care Association
National Family Child Care Association
Tennessee Association for the Education of Young Children
Tennessee Family Child Care Alliance
Tennessee School-Age Care Alliance
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Cookeville, TN 38505
Phone : (931) 372-6561
242 E. 10th Street Foundation Hall, Rm 117
Tennessee Technological University
Center of Excellence for Learning Sciences Revised 12/16/2013
Tennessee State University
TSU-TECTA Form: TECTA Student Information
Complete this portion only the first time you receive TECTA services
Highest educational achievements before seeking TECTA support
< 9
th
grade 9
th
– 12
th
grade (no diploma) High School Graduate/GED
some college Technical certificate Associate Applied Science
Associate Baccalaureate Masters/Doctorate
College or university of highest degree ________________________________________________________
Major: Early Childhood Education Elementary Education Special Education Other _______________
Graduation Date ______/_________
Parents Educational Levels:
Mother < 9
th
grade 9
th
– 12
th
grade (no diploma) High School Graduate/GED
some college certificate Associate
Baccalaureate Masters/Doctorate
Father < 9
th
grade 9
th
– 12
th
grade (no diploma) High School Graduate/GED
Vome college  certifi
cate  Associate
Baccalaureate
Masters/Doctorate
Professional Objectives
Why do you want to participate in TECTA training? (Check all that apply):
Further my education Help with my job search Improve my job skills Obtain CDA Obtain raise
I have completed other early childhood training during the last 12 months Yes No
Was the training required by your employer? Yes No
Do you plan to continue working in child care? Yes No
If no, please tell why_________________________________________________________________
NOTICE: If you have changed your name and/or address since you last enrolled in a TECTA-sponsored course, please fill out a
Change of Name/Address form and return it as soon as possible to the local TECTA site.
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Completed 19 November 2019

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