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T.E.A.C.H. Early Childhood VERMONT Associate Degree Family Child Care Provider Scholarship Application

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T.E.A.C.H. Early Childhood® VERMONT Associate Degree Family Child Care Provider Scholarship Application

Date: _____________________

Ethnicity

Do you consider yourself….?

 White

 Black, African Am.

Or Negro

 American Indian or Alaska Native

 Asian Indian

 Japanese

 Native Hawaiian

 Chinese

 Korean

 Guamanian or Chamorro

 Filipino

 Vietnamese

 Samoan

 Other Asian:

________________

 Other Pacific Islanders:

________________

 Other race:

________________

Are you of Hispanic, Latino or Spanish origin?

 No

 Yes, Mexican, Mexican American, Chicano

 Yes, Puerto Rican

 Yes, Cuban

 Other Hispanic, Latino or Spanish How did you hear about the T.E.A.C.H. Early Childhood® Project?

 Presentation

 Mailing

 CCR&R Agency

 College

 My Center Director

 T.E.A.C.H.

Recipient

 Workshop

 Website

 Other (please specify):

________________

________________

________________

Name

Phone Number Home: Work: Cell:

Email Address City, State, Zip County SSN

Date of Birth (mm/dd/yyyy) Gender

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T.E.A.C.H. Early Childhood® VERMONT Associate Degree Family Child Care Provider Scholarship Application

Employment Status What is your current job title?

 Teacher Family Child Care Provider

Assistant Teacher Non-Teaching Professional Staff

Administrator Non-Teaching Support Staff

Director

Beginning date of employment at current facility? ________________

What is your current hourly wage? (see worksheet) ________________

How many hours per week do you work? ________________

How many months per year do you work? ________________

How many children are in your classroom or child care home? ________________

How long have you worked in the field of early childhood education?

Less than 2 years 6-10 years

2-5 years 10+ years What age groups do

you teach? (please check all that apply)

Infants (0-12months) Preschool (37 months-PreK)

Toddler (13-36 months) School Age

Which CCV campus would be your primary site to attend classes?

________________________________________________

When would you like your scholarship to begin? (circle one)

FALL SPRING SUMMER ___________ (year)

Please check the box that best describes your educational history:

 No high school diploma

 High school diploma/GED

 1-year certificate

 CDA

 VCCICC Apprenticeship Certificate

Associate Degree (Major:

_____________________)

Bachelor Degree (Major:

_____________________)

Masters Degree (Major:

__________________)

Doctorate Are you currently enrolled at a CCV?  Yes  No

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T.E.A.C.H. Early Childhood® VERMONT Associate Degree Family Child Care Provider Scholarship Application

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

 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

Statement of Income

Job #1 Employer _______________________________________________________

Hours/Week ____________ Earnings _________________ per _______________

Job #2 Employer _______________________________________________________

Hours/Week _____________ Earnings _________________ per _______________

Have you applied for any other financial aid (such as Pell Grants, Smart Start Grants or student loans)?

 YES  NO

Source of financial aid #1 _____________________________

Date of application ______________

Application Status:  AWARDED  DENIED  PENDING Source of financial aid #2 _____________________________

Date of application ______________

Application Status:  AWARDED  DENIED  PENDING YOUR TOTAL INCOME $____________________________

YOUR TOTAL FAMILY INCOME (your spouse included) $_______________________

STATEMENT & SIGNATURE OF APPLICANT

I attest to the fact that the information that I have provided is true and accurate. Based on this information I am applying to VAEYC for a scholarship to help pay the cost of educational

expenses.

______________________________________________________ __________________

Signature of Applicant Date

PLEASE COMPLETE THE FOLLOWING WORKSHEET FROM YOUR PRIOR YEARS TAXES OR IF YOU ARE A RECENTLY REGISTERED PROVIDER, FROM YOUR INCOME AND EXPENSES FROM THE PRIOR MONTH

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T.E.A.C.H. Early Childhood® VERMONT Associate Degree Family Child Care Provider Scholarship Application

FAMILY CHILD CARE PROVIDER MONTHLY INCOME WORKSHEET

Instructions: This sheet is to help you determine your monthly income and expenses for your family child care home. For each question, use the amount you made or spent last month.

Total Amount Paid to You by Parents Each Month

Total Amount Paid to You through Child Care Subsidies Each Month

Monthly CACFP Reimbursement

Monthly Public School Partnership Income

Other

Total Monthly Income

How much did you spend for your business last month?

Advertising

Car & Truck Expenses Contract Labor Depreciation Employee Benefits Insurance

Rent/Mortgage

Legal & Professional Services Office Expenses

Other Business Property Repairs & Maintenance Supplies

Taxes & Licenses Travel

Utilities Wages

Other Expenses

Expenses for Use of Home

Total Monthly Expenses

˗

˭

Total Monthly Income minus Total Monthly Expenses equals Monthly Earnings

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T.E.A.C.H. Early Childhood® VERMONT Associate Degree Family Child Care Provider Scholarship Application

Application Supplement

Which of the following credentials and specializations do you currently hold?

 CDA: Infant/Toddler

 CDA: Preschool

 CDA: Family Child Care Home

 CDA: Home Visitor

 Apprenticeship Certificate

 Specialization: Bi-Lingual (language:

________________)

 [State] Issued Credential

 Post BA (state teaching license) Have you taken any college courses in the past two years (this may include courses offered through the Apprenticeship Program)?

 YES

 NO

Have you taken any ECE credits in the past two years (this may include courses offered through the Apprenticeship Program)?

 YES how many? ____________

 NO (enter zero into ‘how many?’)

What is your preferred language for learning? ______________________________

Family Structure

How many people live in your household?

______________

Have either of your parents or any of your brothers or sisters attended college?

 YES

 NO

Do either of your parents or any of your brothers or sisters have a college degree?

 YES

 NO

Do you have a BFIS (Bright Futures Information System) Quality- Credentialing Account? YES NO IF YES, PLEASE PROVIDE THE NUMBER: _____________________

Do you have a NAEYC/VAEYC Membership #? YES NO IF YES, PLEASE PROVIDE THE NUMBER: _____________________

Number Relationship Parents Siblings

Spouse/Significant Other Children

Other

For T.E.A.C.H. use only:

Last 4 SSN ______________

Date Completed _______________

Counselor Initials _____________

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T.E.A.C.H. Early Childhood® VERMONT Associate Degree Scholarship Application

Please mail completed application and any required supporting documents (Schedule C Profit & Loss from last year’s taxes) to:

VAEYC P.O. Box 464 Waterbury, VT 05676

Or by emailing it to:

[email protected]

Please call 802-244-6282 with any questions you may have.

References

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