Earn a Childhood Development Associate (Cda) Credential and 31 Credits Toward a Aa Degree

STUDENT REGISTRATION FORM Form due: October 1 (Fall semester), January 7 (Spring semester), May 5 (Summer semester)

Returning Student: yes no Today’s Date:

Name: NOVA Student ID#:

Address: City: State: Zip:

Email: Phone:

Employment Information If currently employed, complete this section, otherwise skip to next section.

Employment Title: Employer:

Address: City/State: Zip:

Supervisor’s Name/Title: Phone #:

Education I have a high school diploma or GED. I have a CDA. I have completed a college English course. I have an associate’s or bachelor’s degree. If so, list degree/major:

Track & Fee I am registering for the ECLI CDA course and college classes (Fee $275.00). I have earned my CDA and am taking college classes only ($50.00)

Fees Fees cover the cost of CDA application, books, childcare, and guidance and career counseling and are based on proof of receipt of Virginia Child Care Provider Scholarship (VCCPS) or other financial aid for two college courses. Fees must be paid in full at time of registration and are nonrefundable. Cash is not accepted for payment of fees.

I attach personal check (payable to “Hopkins House – ECLI”). I attach company check/money order. I wish to pay by credit/debit card: Cardholder Name Card Number Expiration Date Signature

Childcare Yes, I need childcare: # of children: Age(s):