CDA Scholarship

First Name

Last Name

Mailing Address 1

Mailing Address 2

City

County

State

Zip Code

Email Address

Contact Number (Home/Cell)

Work Contact Number

Name of Center/Program

Date of Birth

Gender

Male Female

Primary Language

Do you have daily access to a computer and internet?

Yes No

Family Structure - List everyone in your house and their relationship to you

Household Member 1

Household Member 2

Houehold Member 3

Household Member 4

I have filled out the above and have more than 4 in my house

More than four

Race/Ethnicity - Please let us know how you identify yourself

Black/African-American White/European-American Hispanic/Latino(a) Native American/American Indian Multi-racial Pacific Islander/Hawaii Native Asian/Asian American Other Check all that apply

Additional Information for Race/Ethnicity

Please add any information if Other or you'd like to eloaborate on

Employment Status:

Begining date of employment at current work place

Hours worked per week

Current wage/salary

$ per Hour

Job Title

Family Provider/Owner Director Lead Teacher Assistant Teacher Program Supervisor Other

If other job title, please enter

Short Job Title Please

Age groups you work with (check)

Birth-3 PreK School Age All Ages

Number of children in your groups

How many years have you worked in a child care center, school age program, or family child care home?

Highest level of education completed

Please select your CDA credential choice

Infant/Toddler Programs (0-36 months) Preschool Programs (36-60 months) Family/Group Programs (0-60 months)

How did you find out about The Scholarship Program?

Write two (2) paragraphs describing how the CDA Scholarship Program will be your best step in professional development

Upload Income Verification

Please upload income verification (PDF or JPG)

Upload Copy of Driver's License

Please upload a picture of your Driver's License (PDF or JPG)

Child Care Information, Training and Referral Services, Serving Livingston & Genesee Counties | 517-548-9112

CDA Scholarship Application for Genesee & Livingston Counties