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TEACH Application CE Fillable

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  • 52 check-boxes
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T.E.A.C.H. Early Childhood® WISCONSIN Scholarship Application
Instructions
1
Fill out application completely and submit all items listed below.
If information is missing or not all questions on the application are answered, your application will be
regarded as incomplete and will not be processed until all materials are received.
2
Complete and return the Program Participation Agreement.
All applicants regardless of position must include this. If you are an employee of a child care program, you
must have approval from your director or center representative. Your director must complete and sign the
Program Participation Agreement page.
3
Submit income verification with your completed application (required).
Your income does not impact your ability to receive a scholarship; however, proof of income is needed to
show that you are meeting certain eligibility requirements and for reporting purposes.
Group Child Care Program Employees: A copy of your most recent paycheck stub or a signed statement
from your center director detailing your rate of pay and hours worked per week.
Group Center Owners: A copy of your most recent paycheck stub or your most recent Schedule C tax
form.
Family Child Care Providers:
o Monthly Income Worksheet
-AND-
o Income verification (one of the following):
▪ A copy of your most recent Schedule C tax form
▪ Copies of receipts for each of the children you care for
▪ A copy of your Child Care Provider Portal (CCPP) Quarterly/Monthly Payments Summary page
for last month
▪ A signed statement detailing your weekly rate and the number of children you care for
YOUR APPLICATION WILL NOT BE PROCESSED UNTIL INCOME VERIFICATION IS RECEIVED!
4
Submit $20 non-refundable application fee (required).
T.E.A.C.H. Scholarship applications require a $20 non-refundable application fee. This fee supports
application processing costs. You may include payment (check or money order) with your application or
make an online application fee payment at: https://wisconsinearlychildhood.org/programs/t-e-a-c-h/t-e-a-c-
h-online-payment-portal/ When making the payment, please leave the Invoice Number blank and enter
your name in the Description box. Please do not send cash or email/fax any credit card information.
As an applicant, you are encouraged to consider carefully your commitment to going to school and make
sure you meet eligibilities. Even if you change your mind about school or are found ineligible for scholarship,
this fee will not be reimbursed. We welcome you to call us if you wish to discuss eligibilities or the
educational pathways supported by T.E.A.C.H. Call 800-783-9322, option 3 or visit our website for more
information: https://wisconsinearlychildhood.org/programs/t-e-a-c-h/
5
Return completed application, program participation agreement and income verification to:
Email: teach@wisconsinearlychildhood.org
Fax: 877-432-7567
Mail: WECA 2908 Marketplace Drive, Suite 101, Fitchburg WI 53719
Application materials will not be returned. Please keep a copy for your records.
Questions? Contact T.E.A.C.H. at 800-783-9322, option 3.
Por favor, llame al 608-729-1064 si tiene preguntas o desea más información sobre el programa de T.E.A.C.H.
Early Childhood® WISCONSIN.
NOTE: For consideration for fall semester, applications must be received no later than July 1; for spring
semester no later than November 1; and for summer no later than April 1.
Applicant Information
Social Security Number (REQUIRED):
First Name
Middle Initial
Last Name
Address
City
State
Zip
County
Work Phone Number
( ) -
Alternate Phone Number ( ) -
Type
Cell
Home
Personal Email Address:
Preferred Contact Method
Email
Phone
Other (may not be available):
Date of Birth:
/ /
Gender:
Pronouns:
Are you legally entitled to work in the United States (i.e., a citizen or national of the U.S., a lawful permanent
resident, an alien authorized to work in the U.S.)?
Yes
No
How many people are living in your home (including yourself)?
Household structure:
Single, no kids
Single parent or grandparent
Married/Partnered, no kids
Married/Partnered parent or grandparent
Do you consider yourself…?
White
Black or African American
American Indian or Alaska Native
Asian (includes Asian Indian, Japanese, Chinese,
Korean, Vietnamese, Filipino or other Asian)
Native Hawaiian or Pacific Islander (includes
Samoan, Chamorro or other Pacific Islander)
Other, two or more races
Other
Do you consider yourself Latinx?
No
Yes (this includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban, Spanish)
Do you prefer to work with a Spanish bilingual scholarship counselor?
Yes
No
Por favor, llame al 608-729-1064 si tiene preguntas o desea más información sobre el programa de T.E.A.C.H.
Early Childhood® WISCONSIN.
How did you hear about the T.E.A.C.H. Early Childhood® Program?
Presentation
My Center Director
Website
Mailing
T.E.A.C.H. Recipient
CCR&R Agency
Workshop
College
Other (please specify):
Are you a WECA Member?
Yes
No
Are you a member of The Registry?
Yes: Registry ID Number
No
Employment Status
How long have you worked in the field of early childhood?
Less than 2 years
2-5 years
6-10 years
10+ years
What is your current job title? If you hold multiple positions, check the title that reflects how you spend the
majority of your time. Check only ONE box.
Family Based Professional
Teacher (Group Leader – School Age)
Assistant Teacher
Administrator (Site Supervisor – School Age): Are you the owner of the center?
Yes
No
Non-Teaching Professional Staff (position)
Non-Teaching Support Staff (may not be eligible for scholarship) (position)
What age groups do you teach? (please check all that apply)
Administrator
Infants (0-12 Months)
Toddler (13-36 Months)
Preschool (37 Months-PreK)
School Age
If you do not know the answer to the following questions, please consult your supervisor.
Date of hire at current facility or for family providers, date you became licensed or certified to provide care in
your home (mm/dd/yyyy) / / (REQUIRED)
How many hours do you work per week?
(Verification required)
How many months do you work per year?
What is your current hourly wage?
(Verification required)
How many children are in your classroom or child care
home?
Education Information: (High School Diploma or GED required to be eligible for scholarship.)
Please check the box that describes your highest level of education:
No high school diploma
High school diploma/GED*
Some college*
1-Year Certificate*
Associate Degree (Major: )
Bachelor’s Degree (Major: )
Masters (Major: )
Doctorate
*Year of HS diploma or completed GED:
*Name of school/institution:
State?:
Please check one that best describes your educational goals:
Earn an Early Childhood or School-Age Credential
Take a few early childhood courses to obtain or upgrade job-related skills
Complete credits to meet YoungStar requirements
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 a Bachelor’s
Degree
Earn a Bachelor’s Degree in Early Childhood Education
Earn or renew a DPI license
Are you currently enrolled at a college?
Yes
No
When would you like your scholarship to begin?
What college would you like to attend?
Fall
Spring
Summer
(year)
NOTE: For consideration for fall semester, applications must be received no later than July 1; for spring semester no later
than November 1; and for summer no later than April 1.
02/22
Scholarship Applying For: (Check only one)
3-8 Credit Model
Administrator Credential
Afterschool & Youth Development Credential
Diversity Credential
Family Child Care Credential
Inclusion Credential
Infant Toddler Credential
Leadership Credential
Preschool Credential
Program Development Credential
Supporting Dual Language Learners Credential
Associate Degree Scholarship
Bachelor’s Degree Scholarship (Must have an associate degree or equivalent.)
How many college credits have you completed? _________ Major: _________________________________
Is there anything else about yourself or your educational or professional development goals that you would like us to
consider while reviewing your application? Please attach a separate sheet if necessary.
Applicants income: List sources of income available to you. For your source of income, you MUST provide a copy
of verification of that income. Please see instructions for explanation of income verification.
Employer #1 (your child care program)
Employer Name:
Earnings Employer #1: $
per hour
per week
per month
How many hours do you work per week?
How many months do you work per year?
Employer #2 (2
nd
job, if applicable)
Employer Name:
Earnings Employer #2: $
per hour
per week
per month
How many hours do you work per week?
How many months do you work per year?
Sources of Financial Aid #1 (Pell grants, Student loans, etc.)
Application Status:
Awarded
Denied
Pending
Sources of Financial Aid #2 (Pell grants, Student loans, etc.)
Application Status:
Awarded
Denied
Pending
Any additional personal income: $ per
YOUR TOTAL PERSONAL INCOME $ per year
YOUR TOTAL FAMILY INCOME $ per year
Application Checklist
Income verification (See instructions for explanation of income verification.)
Program Participation Agreement and Program Information Sheet
$20 Non-Refundable Application Fee (See instructions). Please do not send cash or fax/email any credit
card information.
(Family Child Care Providers only) Monthly Income Worksheet
STATEMENT & SIGNATURE OF APPLICANT
I attest to the fact that information I have provided is true and accurate. Based on this information, I am applying
to the Wisconsin Early Childhood Association for a scholarship to help pay the cost of educational expenses.
Signature of Applicant
Date
This is an application only. This application does not guarantee that the applicant will receive a scholarship.
Applicant and/or Center are not bound by any information contained in this application until applicant is notified
of a scholarship award and a contract is signed by all participating parties.
click to sign
signature
click to edit
02/21
Center Employee – Program Participation Agreement
T.E.A.C.H. Early Childhood® WISCONSIN Scholarship
Agreement must be completed by the center administrator/director and returned with completed application.
T.E.A.C.H. Early Childhood® WISCONSIN Scholarship Program offered through the Wisconsin Early Childhood
Association requires the participation of each scholarship recipient’s employing child care center. In the event
that _____________________________________________ is awarded a scholarship, I understand that the
center agrees to participate in the following ways:
1. Pay 5% of the cost of tuition for courses totaling credit hours as outlined below.
2. Provide 15 hours of paid release time, to be reimbursed by the scholarship program, to the scholarship
recipient employee. Release time is provided regardless of whether or not class is held during
employee’s working hours.
3. Upon completion of the scholarship contract, provide a raise or bonus as specified in table below.
(Please check one to indicate which option you prefer.)
Check
One
Option
Model
Credits
Contract
Length
Commitment Period to
Sponsoring Center
☐
1% Raise
3-8 Credit Model
3-8
3 semesters
6 months + a 2
nd
6 months
at sponsor or another
regulated WI child care
program
☐
$150 Bonus
☐
Limited Option
(No raise or bonus)
3-8 Credit Model
Limited Option
3-8
3 semesters
12 months in a regulated
WI child care program
☐
2% Raise
Credential
9-18
3 semesters
(12 credits)
- or-
4 semesters
(18 credits)
12 months
☐
$300 Bonus
☐
2% Raise
Associate Degree
9-18
3 semesters
12 months
☐
$250 Bonus
☐
2.5% Raise
Associate Degree
19-30
☐
$300 Bonus
☐
2% Raise
Bachelor’s Degree
9-18
3 semesters
12 months + a 2
nd
12
months at sponsor or
another regulated WI child
care program
☐
$250 Bonus
☐
2.5% Raise
Bachelor’s Degree
19-30
☐
$300 Bonus
Yes
No
Yes
No
Does your center have a 4-year-old kindergarten program? (Defined as: Collaboration
between the child care program and the local school district)
If Yes, is this applicant a teacher in the 4K program?
Is the applicant employed and paid directly by the school district?
Yes
No
(Signature of chairperson/owner)
(Telephone #)
(Please print name of chairperson/owner)
(Date)
(Please print name of facility)
click to sign
signature
click to edit
02/21
Sponsoring Center/Family Child Care Program Information
(To be completed by center administrator/director/family child care provider)
Child Care Program Name (as listed on state license)
Program License # (Facility ID #)
YoungStar Participant?
Yes
No
YoungStar Rating: ______
10 Digit Provider #: _____________
Address
City
State
Zip
County
Phone
Fax
( ) -
( ) -
Director’s Name
Director’s Phone
( ) -
Director’s Email Address
Preferred Contact Method
Email
Phone
Other (may not be available): __________________
Program’s Email Address
Program Website
Program Mailing Address (if different)
City
State
Zip
County
Child Care Program is
Licensed
Certified
YoungStar Participant
Auspice: (Check one)
Profit
Non-profit
Head Start
Does your center have a 4K Program (Defined as a collaboration between the child care program and the local
public school district)?
Yes
No
Please check all forms of funding your facility received:
Head Start
Early Head Start
State Head Start
State Pre-K
Title 1
IDEA
State Subsidies: Contracts (WI Shares)
State Subsidies: Vouchers
Is this program accredited by:
NAEYC
NAC (Group Centers)
NAFCC (Family Programs)
Other: __________________
Number of children program is licensed to serve
Number of children currently enrolled
Center Operating Hours
Age groups your program is licensed to serve
If this program is managed by another organization, please complete the parent company information below:
Name
Address
City
State
Zip
County
Return to:
T.E.A.C.H. Early Childhood® WISCONSIN
Wisconsin Early Childhood Association
2908 Marketplace Drive, Suite 101
Fitchburg, WI 53719
Email: teach@wisconsinearlychildhood.org
Fax: 877-432-7567
Questions?
Please contact T.E.A.C.H. at
800-783-9322, option 3
teach@wisconsinearlychildhood.org
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TEACH Application CE Fillable

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Completed 5 March 2022

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