APPLICATION TO ENROLL COMMUNICATION IN THE EARLY CHILDHOOD EDUCATION WORKPLACE

Name: ______(Please Print) Home Mailing Address: ______Street Town State Zip Home Phone: ______

1. Are you a registered family home child care provider? Yes or No or Do you work in a Licensed Child Care Center? Yes or No Name of licensed center where you work:______Work Phone: ______

Is your program in the process of accreditation? Yes or No

2. Where do you hope to take the course? Burlington, Rutland, Vergennes, Montpelier, Springfield, St. Albans (Circle one)

3. Do you have a 2nd choice of location? Yes or No If so where? ______

4. Briefly describe your experience (if any) with taking college courses.

5. Briefly describe how this course relates to your Individual Professional Development Plan. Page two: Application Communication in the Early Childhood Education Workplace (Continued)

6. Please read and sign the statement below (Thank you!)

If accepted into this course I will make every effort to attend all classes and complete assignments. If I find I am unable to attend I will notify the instructor as soon as possible. I understand that state, federal and private funds are being used to fund this course and I agree to share pertinent information for the Council’s data collection needs, including how this course may impact on my income as a child care provider. This information will be used for grant writing and reporting, as well as fulfilling our requirements with the Vt. State Apprenticeship Council. If accepted into this course, I give permission to Community College of Vermont to confirm my participation in this class and to release my final grade to the Industry & Careers Council, Inc.

Signature: ______Date: ______Social Security number: ______

Send by January 5, 2003 to The Vermont Child Care Industry and Careers Council, Inc., 53 Valley View Road, Middlebury, VT 05753

If you have questions about this course, you may contact Jan Walker, Coordinator Vermont Child Care Apprenticeship Program, at 241-2198 or Sue Ryan, Assistant Coordinator, at 660- 2914.

IMPORTANT: Upon receipt of your application, you will be contacted and/or sent a voucher to cover the cost of the course. You will bring this voucher to CCV for the formal process of enrolling as a CCV student. This process may include formal assessment of reading and writing skills.

Job Skills, Education and Compensation