MARYLAND CHILD CARE EDUCATION FOUNDATION

 

Child Care Professional Tuition Reimbursement Program

(January 15^th and July 15^th – Semi-Annual Filing Deadlines)

CURRENT APPLICATION FORM – Revised 12/07

 

Section A – Applicant Information (PLEASE PRINT)

 

1.  _________________________________________________________________________________

                 (Last Name)                                                           (First Name)

 

2.  _________________________________________________________________________________

            (Street Address)                     (City)                           (State)                         (Zip)

 

3.  _________________________________________________________________________________

(Social Security #)                     (Home Phone)                                  (Work Phone)

 

4.  Have you ever received MCCEF tuition reimbursement before? _____NO_____YES 

 

5.  Date of most recent award: ________________________Amount:  ___________________________

 

6.  What level of child related training have you completed?  (Please check ALL that apply)

     ______64 or 90 hour certificate in early childhood education

     ______Child Development Associate Credential (CDA)

     ______Associates Degree   Please specify major: ________________________________________

     ______Bachelors Degree     Please specify major: ________________________________________

     ______Other   Please specify: ________________________________________________________

 

7.  Which of the following have you taken in the past year?

     ______First Aid Certification

     ______CPR Certification

     ______Workshops, seminars, conferences, non-credit courses

     ______Other   Please specify: _________________________________________________

 

Section B – Current College/University Information (if applicable)

 

1.  If you are currently pursuing a degree related to children, please specify degree and number  

     of credits completed toward degree.  Degree: _________________Credits: ______________

 

2.  Name of campus/institution from which you will receive degree: _______________________

 

3.  Date attendance began at this institution: __________Anticipated graduation date: ________

 

4.  Degree sought: ______________________Number of credits currently registered: ________ 

 

Section C – Employment Information

 

1.  Name of Center where employed currently: ______________________________________________

 

2.  Complete address: _________________________________________________________________

 

3.  Position/Title: ________________________________Hours worked per-week: _________________

 

4.  Center Director: _________________________________________ Telephone: ________________

 

5.  Center License No. __________________Exp.Date______ MSCCA Member:  _____Yes_____No

(If you are not a member of MSCCA, proof of membership in another professional organization pertaining to child care or early childhood education (i.e. NAEYC, MCC, etc.) must be provided.

6.  Enclose an individual written professional recommendation from your center owner/director including

     employment verification.  This is a mandatory requirement.

 

Section D – Description of Training Activity (ONLY child care/early childhood education related

                     courses are eligible)

 1.  For what type of training activity are you requesting reimbursement?  (Check one only)

 
     _____Seminar/Workshop _____Conference _____Credit Course _____Continued training

 
2.  Provide a detailed description of the workshop, seminar, conference, continued training, or 

     class:  ___________________________________________________________________________

 

     _________________________________________________________________________________

 

3.  Total amount for training that you are currently seeking reimbursement:  _______________________

 

4.  Name & Location of training site: ______________________________________________________

 

5.  Name of training institutuion/organization________________________________________________

 

6.  Attach required proof of satisfactory completion (course grade MUST be “C” or higher).

 

7.  Attach required copy of a receipted bill (issued by the institution/organization) showing your

     payment of the amount for which this tuition reimbursement is being requested.

 

Section E – Acceptance Conditions and Certification

 Notification of tuition reimbursement awards will be made by mail. 

 Upon receipt of an award, I, the undersigned recipient, agree that I shall provide the MCCEF with a personal note acknowledging receipt of this award, including a brief statement describing the personal benefit it has provided toward my continuing academic efforts.  Should this note NOT be received by the MCCEF within six months following issue of my award, I understand that I will not be eligible for future assistance for a period of 12 months following the current award date.

 
I agree with the terms and conditions set forth above and certify that the information given on this form is true and complete to the best of my knowledge.
 

Signature: _________________________________________________________

Date: ___________________ 

 

Please mail your application and all subsequent correspondence, including proof of completion and acknowledgement of receipt of any award to:

Maryland Child Care Education Foundation

12808-B Ocean Gateway

Queen Anne, MD 21657

Phone:  410-820-9196

Application Revised:  12/1/07