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TA-Degree-BA - TECTA Application for Academic Financial Support

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Tennessee Early Childhood Training Alliance (TECTA)
Southwest Tennessee Community College
737 Union Avenue
M Building, room 316
Memphis, TN 38117
P: (901) 333-5541 F: (901) 333-5750
TECTA Tuition Assistance Check List
For students pursuing a Bachelor Degree
Please review the list below. All materials MUST be attached to your application for your
application to be complete. Incomplete applications cannot be processed.
Tuition Payment Information:
It takes at least a week to process scholarship applications and award the tuition assistance vouchers.
Incomplete applications cannot be processed. Please include ALL the items on the checklist above.
To ensure that TECTA has time to process your paperwork and create a voucher your application is due:
by 3:30 pm on August 12, 2019.
Students are not eligible to receive a refund from federal financial aid and TECTA. If you receive federal
financial aid
your TECTA award amount may be adjusted.
As always, we strongly recommend that all students apply for federal financial aid or other scholarships.
You can apply for federal financial aid online at www.fafsa.gov. You can obtain more information about
financial aid and other scholarships available at Southwest online at www.southwest.tn.edu/financial_aid.
This checklist and all needed documents may be
faxed to 333-5750 or brought to the TECTA office. Student Signature
Completed Applications for Academic Financial Support (1 for each course)
Student Information Form
Student Request to Share Information
Copy of your Fall 2019 course schedule
Printout showing current major/program of study
Copy of check stub as proof of employment in a licensed early childhood program
Grades for the last semester you attended classes
Copy of your tuition bill showing the amount you owe after financial aid is applied.
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 2/2017
Center of Excellence for Learning Sciences w Tennessee State University
TECTA Application for Academic Financial Support
Course Information
College/University __________________________________ Semester Fall Year_2019_______ Textbook Only_____
Course Name ______________________________________ Subject ________Course Number ________ Section _________
Personal Information
Name: Last ___________________________________ First __________________________ Middle ___________________
Social Security Number _____-_____-______ Gender: Male Female
Citizenship: United States Other E-mail ________________________________________________________
Date of Birth _____/_____/_______ Ethnicity: Hispanic Non -Hispanic
Race: Asian Pacific Islander Black Native American Indian/Alaska Native Other
Two or more races White
Home Address ______________________________________________________________________________________
City ______________________________________________________ State ________ Zip ___________
Home County ________________________________ Home Phone (___)____________ Mobile Phone (___)____________
Emergency Contact Person _________________________________Phone (___)____________
Academic degree program this semester: CDA Prep CDA Renewal Technical Certificate
Administrator Credential Associate Degree Bachelors Degree Graduate Degree
Desired Major: Early Childhood Education Elementary Education Pre-K Other________________
Graduation Status: I will graduate this semester: Yes  No
Employment Information
Your Place of Employment ______________________________________ County where you Work ____________________
Work Address _________________________________________________________________________________________
City _______________________________________________ State _______ Zip ___________
Name of Director: Last ________________________________ First _____________________________
Phone (___)____________Fax (___)____________ Director’s E-mail _____________________________________________
Agency Type
Center Dept. of Education Home Visitor Family Group Home High School
Higher Education Registered Unregulated
Eligibility
I understand that I am enrolling in an academic course and will be responsible for completing the class. Failure to complete all
information on this form will result in my application not being processed. If for any reason I cannot finish the course, I will submit
notice to the TECTA office in writing immediately, return textbook(s), and agree to pay the entire tuition fee for re-enrollment in a
TECTA class.
In order to qualify for continued TECTA support, each student must provide a transcript showing that they completed and passed the
previous course(s) for which they received financial support from the TECTA program. By signing below I give permission to the
institution to release my academic progress and records to representatives from the Tennessee Early Childhood Training Alliance.
Signature __________________________________________________________ Date ______________________
Phone : (901) 333-5541
Southwest Tennessee Community College
P O Box 780
University of Memphis
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 2/2017
Center of Excellence for Learning Sciences w Tennessee State University
TECTA Application for Academic Financial Support
Course Information
College/University __________________________________ Semester Fall Year_2019_______ Textbook Only_____
Course Name ______________________________________ Subject ________Course Number ________ Section _________
Personal Information
Name: Last ___________________________________ First __________________________ Middle ___________________
Social Security Number _____-_____-______ Gender: Male Female
Citizenship: United States Other E-mail ________________________________________________________
Date of Birth _____/_____/_______ Ethnicity: Hispanic Non -Hispanic
Race: Asian Pacific Islander Black Native American Indian/Alaska Native Other
Two or more races White
Home Address ______________________________________________________________________________________
City ______________________________________________________ State ________ Zip ___________
Home County ________________________________ Home Phone (___)____________ Mobile Phone (___)____________
Emergency Contact Person _________________________________Phone (___)____________
Academic degree program this semester: CDA Prep CDA Renewal Technical Certificate
Administrator Credential Associate Degree Bachelors Degree Graduate Degree
Desired Major: Early Childhood Education Elementary Education Pre-K Other________________
Graduation Status: I will graduate this semester: Yes  No
Employment Information
Your Place of Employment ______________________________________ County where you Work ____________________
Work Address _________________________________________________________________________________________
City _______________________________________________ State _______ Zip ___________
Name of Director: Last ________________________________ First _____________________________
Phone (___)____________Fax (___)____________ Director’s E-mail _____________________________________________
Agency Type
Center Dept. of Education Home Visitor Family Group Home High School
Higher Education Registered Unregulated
Eligibility
I understand that I am enrolling in an academic course and will be responsible for completing the class. Failure to complete all
information on this form will result in my application not being processed. If for any reason I cannot finish the course, I will submit
notice to the TECTA office in writing immediately, return textbook(s), and agree to pay the entire tuition fee for re-enrollment in a
TECTA class.
In order to qualify for continued TECTA support, each student must provide a transcript showing that they completed and passed the
previous course(s) for which they received financial support from the TECTA program. By signing below I give permission to the
institution to release my academic progress and records to representatives from the Tennessee Early Childhood Training Alliance.
Signature __________________________________________________________ Date ______________________
Phone : (901) 333-5541
Southwest Tennessee Community College
P O Box 780
University of Memphis
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 _Fall__________ Year _2019___________
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.
University of Memphis
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/GE
D
o Some Col
lege 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/GE
D
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/GE
D
o Some Col
lege 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.
Student Request to Share Information
Office of Admission and Records
The University of Memphis
Name of institution where student is enrolled
Student’s Name ______________________________________________________________
(Please Print) Last First Middle Initial
SS# ___________________________________________
Address: _________________________________________________
Street
_________________________________________________
City State Zip Code
Phone: ( )_________ ____
Semester: ________________ Year:____________
I know that the Family Educational Rights and Privacy Act of 1974, as amended
(FERPA), protects the privacy of my student educational records and limits access to the
information contained in those records. Because I receive financial support covering all or part of
my tuition from the Southwest-TECTA program, I am hereby authorizing The University of
Memphis Office of Admission and Records to release my grades and academic status information
to the local TECTA Site Director for transmission to the TSU-TECTA Management Office. The
information will be used to determine and verify my eligibility for continued TECTA financial
support and will be protected in accordance with the provisions FERPA. My grade and academic
status information should be sent to:
Name: _Elizabeth O. Wilson , Southwest -TECTA Director
Address: __Southwest Tennessee Community College ______
__P.O. Box 780 ________________________
__Memphis, TN 38101-0780__ _________________
__(901) 333-5541 ________________________
__________________________________ _____________________________
Student’s Signature Date
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TA-Degree-BA - TECTA Application for Academic Financial Support

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Completed 25 January 2020

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