T.E.A.C.H. Early Childhood Rhode Island Scholarship Application Associate s Model ATR2-1 and ATR2-2 Models

Page 1 of 10 T.E.A.C.H. Early Childhood Rhode Island Scholarship Application Associate s Model ATR2-1 and ATR2-2 Models Center-Based Teachers and Assistant Teachers Date: _ 1. Name: _ 2. Address: County: City: State: Zip: Mailing Address (if different) _ 3. Telephone: Home ( ) Cell ( ) 4. Email Address: _ 5. Social Security #: 6. Birth Date: Gender: _ 7. CCRI College Student ID # 8. Employment Status a. Program Name: City:_ b. Center Phone Number: What is your current job title? What age groups do you teach? (please check all that apply) Teacher Assistant Teacher Administrator Infants (0-12 Months) Toddler (13-36 Months) Family Based Professional Non-Teaching Professional Staff Non-Teaching Support Staff Preschool (37 Months PreK) School Age How many children are in your classroom or child care home? If you are a preschool teacher, what are the ages of the children you teach (e.g. 3 yr olds)? How many hours per week do you work? How many months per year do you work? Beginning date of employment at current facility? What is your current hourly wage? How long have you worked in the field of early childhood? Less than 2 Years 2-5 Years 6-10 Years 10+ Years

Page 2 of 10 9. Ethnicity Are you of Hispanic, Latino or Spanish origin? No Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Other Hispanic, Latino or Spanish 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: _ 10. 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): _ 11. Educational History and Goals: a. Please check the box that best describes your educational history: No high school diploma High school diploma/ged 1-year certificate High school diploma with some college coursework. Associate Degree (Major: _) Bachelor Degree (Major: ) Master (Major: ) Doctorate b. 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 c. Are you currently enrolled at a community college? Yes College Name What is your major or program? _ No

Page 3 of 10 d. When would you like your scholarship to begin? (Circle one and identify starting year) FALL SPRING SUMMER (year) e. Which Community College would you like to attend? Community College of Rhode Island f. If awarded a scholarship what campus would you like to attend? Community College of Rhode Island Liston-Providence Knight -Warwick Flanagan - Lincoln Newport Westerly Satellite g. Educational Information (Attach transcript for all college courses you have taken.) College/ University Dates Attended Degree or Credit Hours h. Do you have a current CDA Credential? Yes No i. Are you within 8 courses of graduating? Yes No 12. Course Selection: Currently what are your top three class choices? You may list course titles or subject areas (for example: Child Development, Curriculum for Young Children, Math 101, or History.) Do not list any courses you have already taken and received credit for. If you do not yet know the answer to this question, academic advisement will be provided to you before you are asked to register for classes. All courses are subject to approval by T.E.A.C.H. Early Childhood Rhode Island. Courses must meet degree requirements. a. b. c.

Page 4 of 10 13. What are your short and long term professional goals in early childhood education? 14. Please provide any additional information you would like us to consider as we review your application.

Page 5 of 10 T.E.A.C.H. Early Childhood Rhode Island 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 GROSS ANNUAL INCOME $_ YOUR TOTAL FAMILY GROSS ANNUAL INCOME (your spouse included) $ STATEMENT & SIGNATURE OF APPLICANT I attest to the fact that the information I have provided is true and accurate. Based on this information I am applying to T.E.A.C.H. Early Childhood Rhode Island for a scholarship to help pay the cost of educational expenses. T.E.A.C.H. Early Childhood Rhode Island is a project of Ready to Learn Providence and The Providence Plan. Signature of Applicant Date PLEASE ATTACH A COPY OF YOUR MOST RECENT PAY STUB HERE

Page 6 of 10 CENTER BASED ASSOCIATE S MODEL TEACHER PARTICIPATION AGREEMENT The Early Childhood Associate s Degree Scholarship Program offered through T.E.A.C.H. Early Childhood Rhode Island requires active participation and cost sharing from each scholarship recipient. In the event that I am awarded a scholarship, I agree to the following participation requirements: 1. Remain enrolled in the Associate s Degree Program in the major of Early Childhood Education at the Community College of Rhode Island. 2. Upon receipt of semester bills from T.E.A.C.H., pay 7.5% of outstanding tuition and associated fees for approved courses at the Community College of Rhode Island. As of 5/1/12 the in-state cost for a three credit course in a fall or spring semester is $551.00. Summer courses cost slightly less. 3. Pay 10% of the cost of required books for each approved semester and for approved courses. 4. Successfully complete 9-15 credit hours at the Community College of Rhode Island during a contract period that will not exceed 12 months. 5. Remain in the employ of my sponsoring program for an additional twelve months following the end of my contract period. 6. Receipt of financial aid is not required to receive a T.E.A.C.H. Scholarship. However all applicants are required to apply for federal, state, and college aid via the completion of a FAFSA form. FAFSA stands for Free Application for Federal Student Aid. FAFSA forms can be accessed and filed through the website www.fafsa.ed.gov. Be sure to access the given website, similar web addresses unnecessarily charge money for processing. The site you are referred to is free. Applicants are required to complete a FAFSA form prior to submitting their initial T.E.A.C.H. Scholarship Application and every spring thereafter for the following academic year. If you have questions about this process, or need help completing the online FAFSA form, please contact the Educational Opportunity Center at CCRI, 455-6028. The T.E.A.C.H. scholarship office may also be consulted. Due to the award cycles of FAFSA, it may be necessary for new T.E.A.C.H. summer applicants to apply for FAFSA two times within one T.E.A.C.H. contract period. _ Signature of T.E.A.C.H. Scholarship Applicant Date Please Print Name

Page 7 of 10 T.E.A.C.H. Early Childhood Rhode Island Early Childhood Associate s Model Scholarship Project Center Participation Agreement Page 1 This agreement must be completed by the center director and center owner or board chairperson. The T.E.A.C.H. Early Childhood Associate s Model Program offered through T.E.A.C.H. Early Childhood Rhode Island, a project of Ready to Learn Providence and The Providence Plan, requires the participation of each scholarship recipient s employing child care center. In the event that is (Applicant Name) awarded a scholarship, I understand that the center agrees to participate in one of the following ways. (Please check to indicate which model you prefer): _ATR2-1 Model One - (Small Raise Option) 1. Center pays 7.5% of the cost of tuition and associated fees for courses totaling 9-15 credit hours at the Community College of Rhode Island for the scholarship employee. 2. Center provides three hours of release time each week of each approved semester for each scholarship employee. (Forty five hour maximum for 15 week academic year terms, maximum of 18 hours for summer terms.) Release time is provided for campus and on-line courses. T.E.A.C.H. will cover 75% of the cost of release time based on a rate of $9.00 per hour. 3. At the end of the contract, and upon the successful completion of 9-15 credit hours, the center will issue a 1.5% annual raise above any other expected or earned raise. T.E.A.C.H. will contribute an additional $585 in bonus pay. _ATR2-2 Model Two - (Small Bonus Option) 1. Center pays 7.5% of the cost of tuition and associated fees for courses totaling 9-15 credits at the Community College of Rhode Island for the scholarship employee. 2. Center provides three hours of release time each week of each approved semester for each scholarship employee. (Forty five hour maximum for 15 week academic year terms, maximum of 18 hours for summer terms.) Release time is provided for campus and on-line courses. T.E.A.C.H. will cover 75% of the cost of release time based on a rate of $9.00 per hour. 3. At the end of the contract, and upon the successful completion of 9-15 credit hours, T.E.A.C.H. will award a $585 bonus. The center will be responsible for an additional bonus of $200 to be paid by the mid-point of the commitment year. Center Auspice: Profit _ Non-profit _ BrightStars Rating: 1 _2 _3 _4 _5_ Candidate Name for this contract: _ Number of hours candidate works per week: Months worked per year: Hourly rate of pay: We the undersigned agree to the terms indicated in the above T.E.A.C.H. Center Participation Agreement. (Please print name of Director) (Signature of Director) (Date) (Please print name of Chairperson/Owner)* Is your center accredited? Yes_ No_ If yes, by whom? _ Does your facility accept children with DHS subsidy? Yes No What percentage of your enrollment receives DHS Subsidy? ------------------------------------------------------------------------------------------- Is this child care program owned or managed by another organization: Yes No If yes, give the parent company name/address: (Signature of Chairperson/Owner) (Date) *Two signatures are required in all circumstances. This requirement applies to all programs including when a director and the owner are the same person or a program is a Head Start or Community Action program. If there is a Board, a board signature is required.

Page 8 of 10 T.E.A.C.H. Early Childhood Rhode Island Early Childhood Associate s Model Scholarship Project Center Participation Agreement - Page 2 Program Name: Phone # Center Mailing Address: Physical Address: (if different from mailing): E-mail Address: _ Program Fax #:_ DCYF Provider ID # License #_ License Capacity: Present Enrollment: _ Program /Provider Taxpayer Identification #: Name and position of the administrator who should receive T.E.A.C.H. approval and billing information _ Address of above administrative contact person Name and e-mail of site director if different than above (Please print information) Please check all forms of funding your facility receives: Head Start Title 1 Early Head Start IDEA State Head Start State Subsidies: Contracts State Pre-K State Subsidies: Vouchers Return This Application with Verification of Candidate s Income, Evidence of Successfully Completing FAFSA, Unofficial Transcripts, and a Copy of Your Program s Current DCYF License to: T.E.A.C.H. Early Childhood Rhode Island Ready to Learn Providence 945 Westminster Street, Providence, Rhode Island 02903 If you have any questions, please contact Maura Pearce or Samantha McCormack at (401) 490-9960 mpearce@provplan.org smccormack@provplan.org

Page 9 of 10 T.E.A.C.H. Scholarship Application Checklist T.E.A.C.H. Center-based Associates Candidates: I have applied to CCRI. Applications are available at www.ccri.edu. Previous degree students who have not taken courses in the last two years must apply for readmission. An admission application submitted online is free; submitted paper applications have a fee of $20.00. I have included an admission letter of acceptance, or a CCRI transcript that shows proof of recent enrollment. My submitted letter of acceptance or current transcript indicates that my declared major is Early Childhood Education/Child Development. Students who have an alternate major must change their major online via their CCRI web account, or through the College s Office of Enrollment Services. I have completed Accuplacer tests and had my scores and course placement information faxed to the T.E.A.C.H. Scholarship Project Office (Attention: Maura Pearce or Samantha McCormack 401-490-9959). The Accuplacer test assesses proficiency in English, math, and reading. Tests may be arranged through CCRI s Department of Advising and Counseling (see reverse side of this sheet for contact info). For scores to be sent to TEACH you must indicate to the CCRI testing center that you are applying for a TEACH scholarship. A practice Accuplacer test is available at http://www.ccri.edu/advising/new_students/accuplacerreviewpacket.pdf I have paid any outstanding balance/bills owed to the Community College of Rhode Island (CCRI) and to any other colleges I attended. I understand that I will not be allowed to register for classes if I owe any money to CCRI and that my enrollment may be restricted if I owe money to other colleges. I have completed all information and signed and dated the application. I have submitted a copy of transcripts for all college courses I have taken. I have submitted verification of income from all my current places of employment. (e.g. recent paystub) I have had the Director and Owner of my center, and as applicable, a member of the Board sign the T.E.A.C.H. Center Participation Agreement in the scholarship application. The Center Participation Agreement must have two signatures even if the signing administrator and owner is the same person. I have submitted a current copy of my program s DCYF license I have completed a FAFSA form (Free Application for Federal Student Aid) form. Consult www.fafsa.ed.gov for filing information. (The provided FAFSA site is free. Beware of similar sites that cost money!) I have submitted verification that I have completed the FAFSA process successfully. I have included a copy of any notice or an award or denial of aid. (T.E.A.C.H. applicants must complete the FAFSA process. However, receipt of financial aid through FAFSA is not required.) T.E.A.C.H. Early Childhood Scholarship Project Ready to Learn Providence 945 Westminster Street Providence, Rhode Island 02903 If you have any questions, please call Maura Pearce or Samantha McCormack at 401-490-9960 mpearce@provplan.org smccormack@provplan.org For Information on the Accuplacer Test, to make an appointment, or to request accommodations see reverse side.

Page 10 of 10 Community College of Rhode Island Department of Advising and Counseling To arrange for accommodations regarding disabilities, call: Warwick 401-825-2301 Warwick 401-825-2169 Lincoln 401-333-7159 Lincoln 401-333-7329 Providence 401-455-6149 Providence 401-455-6064 Newport 401-851-1631 Newport 401-851-1650 For assistance in completing FAFSA forms, contact a CCRI Educational Opportunity Center: Providence, Warwick, Lincoln 455-6028; Newport 825-1638