<p> APPLICATION TO ENROLL COMMUNICATION IN THE EARLY CHILDHOOD EDUCATION WORKPLACE</p><p>Name: ______(Please Print) Home Mailing Address: ______Street Town State Zip Home Phone: ______</p><p>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: ______</p><p>Is your program in the process of accreditation? Yes or No</p><p>2. Where do you hope to take the course? Burlington, Rutland, Vergennes, Montpelier, Springfield, St. Albans (Circle one)</p><p>3. Do you have a 2nd choice of location? Yes or No If so where? ______</p><p>4. Briefly describe your experience (if any) with taking college courses. </p><p>5. Briefly describe how this course relates to your Individual Professional Development Plan. Page two: Application Communication in the Early Childhood Education Workplace (Continued)</p><p>6. Please read and sign the statement below (Thank you!)</p><p>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. </p><p>Signature: ______Date: ______Social Security number: ______</p><p>Send by January 5, 2003 to The Vermont Child Care Industry and Careers Council, Inc., 53 Valley View Road, Middlebury, VT 05753</p><p>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.</p><p>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. </p><p>Job Skills, Education and Compensation</p>