RETURN COMPLETED APPLICATION TO INDIANA AEYC
T.E.A.C.H. Early Childhood® INDIANA is a licensed program of Child Care Services Association. This program is supported by funding from the Child Care
Development Block Grant awarded to the Office of Early Childhood and Out-of-School Learning, a division of the Indiana Family and Social Services Administration.
T.E.A.C.H. Early Childhood
®
INDIANA Scholarship
2955 N Meridian Street, Suite 120
Indianapolis, IN 46208
t (855) 484-2392 / o (317) 356-6884
f (317) 259-9489 /
inaeyc.org
CDA Assessment/Renewal Application
pg 1 of 6
Date of Hire: Rate of pay: $ /hour Hours worked/week:
How long have you worked in the eld of early childhood?
What is your current job title?
What age groups do you teach?
(please check all that apply)
How many children are in your classroom?
EMPLOYMENT STATUS
DATE:
Less than 1 year 1-5 years 6-10 years 10+ years
Infants (0–12 Months) Toddler(13–36 Months) Preschool (37 Months–PreK) School Age Home Visitor
Name: SSN#:
Street Address:
City: State: Zip: County:
Home Phone: Cell Phone: Work Phone:
Email Address:
Date of Birth(mm/dd/yyyy): Gender:
Family Structure: How many in household:
Married Single Other:
Male Female
Do you consider yourself...?
White
Black/African American
American Indian/Alaska Native
Other Asian
Native Hawaiian
Guamanian/Chamorro
Japanese
Korean
Vietnamese
Asian Indian
Chinese
Filipino
Samoan
Other:
Are you of Hispanic, Latino, or Spanish origin?
No
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Other Hispanic, Latino, or Spanish
Scholarship Model Applying for: (CHOOSE ONLY ONE)
Child Development Associate (CDA) Assessment Child Development Associate (CDA) Renewal
Teacher Director Family Child Care Owner Other:
Teacher Assistant Assistant Director Early Head Start Home Visitor
Are you currently enrolled at a community college/university?
Have you begun the Council for Professional Development Recognition on line application?
No Yes
No Yes
RETURN COMPLETED APPLICATION TO INDIANA AEYC
T.E.A.C.H. Early Childhood® INDIANA is a licensed program of Child Care Services Association. This program is supported by funding from the Child Care
Development Block Grant awarded to the Office of Early Childhood and Out-of-School Learning, a division of the Indiana Family and Social Services Administration.
T.E.A.C.H. Early Childhood
®
INDIANA Scholarship
2955 N Meridian Street, Suite 120
Indianapolis, IN 46208
t (855) 484-2392 / o (317) 356-6884
f (317) 259-9489 /
inaeyc.org
CDA Assessment/Renewal Application
pg 2 of 6
STATEMENT & SIGNATURE OF APPLICANT
Check All
I attest to the fact that the information that I have provided is true and accurate. Based on this information I am applying
to the Indiana AEYC/T.E.A.C.H. Early Childhood® INDIANA for educational scholarship. I am aware that I may be required
to pay a portion (5-10%) of the cost of the Council’s application fee. I am also aware there is a contractual commitment to
work for my sponsoring center or continue to own my family child care after completion of each contract. I understand I
must report all changes of information within 7 calendar days.
I attest I have met or exceeded the requirement for a National Criminal History Check as set forth in IC 10-13-3-3 in
Early Childhood and Out-of-School Learning, a division of the Indiana Family and Social Services Administration.
I understand & accept that the Council for Professional Recognition may share my CDA Credential status with Indiana AEYC.
Signature of Applicant: Date:
Printed Name of Applicant:
Employer: License/Registered/IDOE#:
Earn a Child Development Associate (CDA) Credential (Infant/Toddler | Preschool | Family Child Care)
Take a few early childhood courses to meet early childhood education equivalency
Earn an Early Childhood Associate Degree (Associate of Applied Science)
Earn an Early Childhood Associate Degree and transfer to a four-year college/university to earn a Bachelor Degree (TSAP)
Earn a Bachelor Degree in Early Childhood Education with teaching licensure
Earn a Bachelor Degree in Early Childhood Education (non-licensure)
Earn an Bachelor Degree in Child Development
Earn a Master’s Degree in Early Childhood Education/Child Development
Earn a Master Teacher Credential (graduate level)
What best describes your educational goals at this time?
Educational History:
No high school diploma
High school diploma/HSE
CDA Credential—Expiration Date:
Associate Degree—Major:
Bachelor Degree—Major:
Masters Degree—Major:
Presentation
Mailing
CCR&R Agency
My Center Director
T.E.A.C.H. Recipient
Workshop
Indiana AEYC Conference
Indiana AEYC Website
College
Coach
Other:
How did you hear about the T.E.A.C.H. Early Childhood® INDIANA Project?
(pay stubs for the last 30 days
OR Taxes–1040-pg 1 & 2, Schedule C business)
copy of program license/registration
(copy of what is in your portfolio)
all items checked on application checklist
PLEASE ATTACH the following documentation (required to process your application)
RETURN COMPLETED APPLICATION TO INDIANA AEYC
T.E.A.C.H. Early Childhood® INDIANA is a licensed program of Child Care Services Association. This program is supported by funding from the Child Care
Development Block Grant awarded to the Office of Early Childhood and Out-of-School Learning, a division of the Indiana Family and Social Services Administration.
T.E.A.C.H. Early Childhood
®
INDIANA Scholarship
2955 N Meridian Street, Suite 120
Indianapolis, IN 46208
t (855) 484-2392 / o (317) 356-6884
f (317) 259-9489 /
inaeyc.org
CDA Assessment/Renewal Application
pg 3 of 6
STATEMENT OF INCOME
Statement of Income—Completed by all applicants
List sources of income available to you. For your source of
A statement from your employer indicating your weekly
working hours and rate of pay (on center letterhead) or copies
of all your pay stubs for the last 30 days will verify earnings.
Family child care home providers must also complete
the Statement of Income on the right, along with legal
documentation of income.
A. Employer #1:
B. Earnings Job #1: $ /hour
C. Number of hours worked /week
D. Employer #2:
E. Earnings Job #2: $ /hour
F. Number of hours worked /week
G. Are you currently a student?
H. *Scholarship/Grant #1: $
I. *Scholarship/Grant #2: $
J. *Student Loan: $
K. Child support/alimony: $
L. TANF/Supplemental Security Income: $
M. YOUR Total Income $
Spouse’s Income (documentation not required)$
N. Total FAMILY income (or $
1. What is the total amount paid to you by parents each week?
(Do not include CCDF Voucher Payments) $
2. Total Monthly parent fees
[Multiply Line 1 by 4.33 (weeks/month)] $
3. Total Monthly USDA Child & Adult Care Food Program
reimbursement? $
4. Total Monthly subsidy reimbursement for children in your care?
(include CCDF Voucher payments here) $
5. Total Monthly Revenue [Add lines 2, 3, and 4] $
Average Monthly expenditures for children in your family child
care home for the following categories: (receipts not needed)
6. Food: $
7. Toys: $
8. Assistant/Substitute wages: $
9. Crafts/Supplies: $
10. Transportation ($0.45/mile): $
11. Training fees: $
12. Gifts for children/families: $
13. Other: $
14. Total Monthly Expenses [Add lines 6-13] $
Family Child Care Owners—(Additional information required)
Use this to calculate your monthly earnings from your family
child care home. Base your answers on last month’s receipts.
of your Schedule C(taxes), receipts from each child in your care
or a statement detailing your weekly rate and the number of
children in your care.
No Yes*
REVENUE (line 5) $
[minus] EXPENSES (line 14) —$
TOTAL MONTHLY EARNINGS
(enter on Line B, left)
$
RETURN COMPLETED APPLICATION TO INDIANA AEYC
T.E.A.C.H. Early Childhood® INDIANA is a licensed program of Child Care Services Association. This program is supported by funding from the Child Care
Development Block Grant awarded to the Office of Early Childhood and Out-of-School Learning, a division of the Indiana Family and Social Services Administration.
T.E.A.C.H. Early Childhood
®
INDIANA Scholarship
2955 N Meridian Street, Suite 120
Indianapolis, IN 46208
t (855) 484-2392 / o (317) 356-6884
f (317) 259-9489 /
inaeyc.org
CDA Assessment/Renewal Application
pg 4 of 6
Signature of Recipient: Date:
Printed Name of Recipient:
RECIPIENT PERSONAL RESPONSIBILITIES AGREEMENT
This is an agreement between T.E.A.C.H. Early Childhood® INDIANA and the scholarship recipient
Printed Name of Applicant
Should you be awarded a T.E.A.C.H. Early Childhood® INDIANA Scholarship - You should be very proud of yourself
for investing in your own future and increasing your education. This scholarship represents an amazing opportunity –
As a T.E.A.C.H. Early Childhood® INDIANA Scholarship Recipient, I will:
• Complete the credential process and be a responsible candidate. This is a great opportunity that should be
taken seriously.
• Regularly communicate with my TEACH professional development advisor. My advisor is available to help guide
me through the process of obtaining my credential, work and family responsibilities. He/She is just a phone call
or email away and can answer many questions.
• Contact my PD Advisor regarding any changes to my employment or application status, or if I am having
• Submit my CDA Credential within 72 business hours (3 business days) following grades being posted. Keeping
my scholarship record up-to-date is critical to ensuring that I can get my bonus without unnecessary delays.
• Pay my bills from T.E.A.C.H. in a timely manner. It is my responsibility to ensure that I am meeting all of my
obligations.
•
RETURN COMPLETED APPLICATION TO INDIANA AEYC
T.E.A.C.H. Early Childhood® INDIANA is a licensed program of Child Care Services Association. This program is supported by funding from the Child Care
Development Block Grant awarded to the Office of Early Childhood and Out-of-School Learning, a division of the Indiana Family and Social Services Administration.
T.E.A.C.H. Early Childhood
®
INDIANA Scholarship
2955 N Meridian Street, Suite 120
Indianapolis, IN 46208
t (855) 484-2392 / o (317) 356-6884
f (317) 259-9489 /
inaeyc.org
CDA Assessment/Renewal Application
pg 5 of 6
CHILD CARE FACILITY PARTICIPATION AGREEMENT
To be used by applicants seeking CDA Assessment and completed by SPONSORING CENTER
The T.E.A.C.H. Early Childhood® INDIANA Scholarship, offered through the Indiana Association for the Education of
Young Children, requires the participation of each scholarship recipient’s employing child care center. In the event that
Printed Name of Applicant
is awarded a scholarship, I understand that the center agrees to participate
in one of the following ways
(please check one to indicate which option you prefer):
OPTION 1
The participant agrees to:
1. Pay 10% of CDA Assessment/Renewal fee ($42.50 or $12.50)
2. Submit Assessment/Renewal application to T.E.A.C.H. Early Childhood® INDIANA
3. Complete Assessment/Renewal
4. Commit to remaining in child care for 6 months after receiving the CDA Credential
5. Notify T.E.A.C.H. Early Childhood® INDIANA upon attainment of CDA Credential
The Center/Home agrees to:
1.
OPTION 2
The participant agrees to:
2. Submit Assessment/Renewal application to T.E.A.C.H. Early Childhood® INDIANA
3. Complete Assessment/Renewal
4. Commit to employment at sponsoring center for 6 months after receiving the CDA Credential
5. Notify T.E.A.C.H. Early Childhood® INDIANA upon attainment of CDA Credential
The Center/Home agrees to:
1. Pay 10% of CDA Assessment/Renewal fee ($42.50 or $12.50)
2.
OPTION 3
The participant agrees to:
1. Pays 5% of CDA Assessment/Renewal fee ($21.25 or $6.25)
2. Submit assessment application to T.E.A.C.H. Early Childhood® INDIANA
3. Complete Assessment/Renewal
4.
receiving the CDA Credential
5. Notify T.E.A.C.H. Early Childhood® INDIANA upon attainment of CDA Credential
The Center/Home agrees to:
1. Pay 5% of CDA Assessment/Renewal fee ($21.25 or $6.25)
2.
By signing below I assure the option was chosen by the employer.
Sponsoring Center Name:
Signature of Chairperson/Owner: Date:
Printed Name of Chairperson/Owner:
RETURN COMPLETED APPLICATION TO INDIANA AEYC
T.E.A.C.H. Early Childhood® INDIANA is a licensed program of Child Care Services Association. This program is supported by funding from the Child Care
Development Block Grant awarded to the Office of Early Childhood and Out-of-School Learning, a division of the Indiana Family and Social Services Administration.
T.E.A.C.H. Early Childhood
®
INDIANA Scholarship
2955 N Meridian Street, Suite 120
Indianapolis, IN 46208
t (855) 484-2392 / o (317) 356-6884
f (317) 259-9489 /
inaeyc.org
CDA Assessment/Renewal Application
pg 6 of 6
Full Legal Center/Home/Registered Ministry Name:
Name of Director:
Facility Address:
City: State: Zip: County:
Facility Phone: Facility Fax:
Facility Email Address:
License/RM Certicate #
(please attach a copy): Exempt:
Capacity/Number of Children Enrolled:
Head Start
We assure that this agency/program/school has met or exceeded the requirement for a National Criminal History
Check of all its child care employees and volunteers in compliance with the Indiana Legislation SEA 305 and HEA
1494 effective July 1, 2013, and as required by the Ofce of Early Childhood and Out-of-School Learning, a division of
the Indiana Family and Social Services Administration.
Signature of Chairperson/Owner: Date:
Printed Name of Chairperson/Owner:
No Yes
No Yes
Please check all forms of funding your facility receives:
Licensed School Head Start Public School Registered Ministry Private School
Center Type:
Center Auspices:
Is this Child Care Program owned or managed by another organization?
(Head Start or Multi-Site Programs)
Name of Parent Company:
Address:
Accredited:
Paths to QUALITY™:
No
Yes: Level: 1 2 3 4
No Yes: Accrediting Body:
CHILD CARE FACILITY INFORMATION
IDEA
On My Way PreK (OMWPK)
Head Start
Early Head Start
State Subsidies: Contracts
Elementary School Education Act (ESEA)
