Print out the application and return
to:
If you have any questions, please feel free to call (207) 973-3539 or 1-800-215-4942, or email: apate@penquis.org. Thank you for your interest in the Early Education Profession Project. Personal Information: Name: ___________________________________________ ___ male ___ female Mailing Address: ________________________________________________________ Phone: _________________________ E-mail: ____________________________ Are you eligible to work in the United States? ___ yes ___ no Race: African American Latino or Hispanic Native American Caucasian Asian, Pacific Islander Other ___________ Are you currently receiving TANF? ___ yes ___ no Total monthly household income __________________ Sources of income ___________________________ ___________________________ ___________________________ Number of people in your household _____________ How did you learn about Early Education Profession Project? _____ TANF _____ Career Center _____ ASPIRE _____ Transition Team _____ other Please explain ______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Education/Training: A. High School Diploma or equivalent ___ yes ___ no B. Describe post high school education/training ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Skills and qualifications: 1. What strengths would you bring to a child care business? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. What do you hope to gain by applying to the Early Education Profession Project? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. What would you identify as personal barriers to starting your child care business? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. Have you ever, or do you presently, use a computer? ___ yes ___ no A. Check the computer programs you use: O Microsoft Word O Microsoft Excel O E-mail O Maintain a www.page (web page) O Microsoft ACCESS O Microsoft Publisher Employment history: Employer: ______________________________________________ Name of Supervisor: _______________________________________ Telephone Number: _______________________________________ Business Type: ___________________________________________ Address: ________________________________________________ City, state, zip: ___________________________________________ Length of Employment (Include Dates): _______________________ Position & Duties: ________________________________________ ________________________________________________________ Reason for Leaving: _______________________________________ ________________________________________________________ May we contact this employer for references? ___ yes ___ no Employer: ______________________________________________ Name of Supervisor: _______________________________________ Telephone Number: _______________________________________ Business Type: ___________________________________________ Address: ________________________________________________ City, state, zip: ___________________________________________ Length of Employment (Include Dates): _______________________ Position & Duties: ________________________________________ ________________________________________________________ Reason for Leaving: _______________________________________ ________________________________________________________ May we contact this employer for references? ___ yes ___ no References: Please list three persons (not relatives) who can tell us about your employment and your character. Name: _______________________________ Phone: _________________ Address: _____________________________ City: _________________ State: _________ Relationship: __________________________ Name: _______________________________ Phone: _________________ Address: _____________________________ City: _________________ State: _________ Relationship: __________________________ Name: _______________________________ Phone: _________________ Address: _____________________________ City: _________________ State: _________ Relationship: __________________________ If you are interested in starting your own Family Child Care business, please complete this next section of the application: Please describe your goals for your child care business: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 1. Do you have any need for a loan for business startup? ___ yes ___ no If yes, how much do you think you will require? __________________ 2. Have you been to a bank or some other financial institution to try to acquire financing for your business? ___ yes ___ no If yes, which one? _______________________________ 3. Do you have any personal savings to put into your business venture? ___ yes ___ no 4. Have you ever written a business plan for your business? ___ yes ___ no 5. Do you need help with record keeping? ___ yes ___ no 6. What do you consider to be your greatest business strengths? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7. What areas do you struggle the most with? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please read the following and sign the Application Form below. The information provided in this application is accurate to the best of my knowledge. I understand that the Early Education Profession Project makes the decision as to whether I am approved for membership into the Early Education Profession Project. Signature:
__________________________ Date: ___/___/_____ To the Applicant: Please answer the following: 1. Have you ever been arrested for or charged with any offense relating to child sexual abuse? __________________________________________________________________________ What was the final outcome? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. Do you have any pending charges against you relative to child sexual abuse? ______________________________________________________________________________ 3. Do you have any convictions related to other forms of child abuse and/or neglect? ______________________________________________________________________________ 4. Do you have any convictions for any violent crime? ______________________________________________________________________________ Signed: ______________________________________________ Date: __________________
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