WISEE (Workforce Innovation to Support Early Education) Application

Application is not complete until the final signature is completed at the end of this application.

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* 1. Application Date

Date / Time

Date

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* 2. Please check which one reflects your current status:

High School Student

Early College

Early Childhood Teacher (Complete all Questions)

Neither of the above, but taking at least one 3 credit hour early childhood class

Other (please specify)

General Information

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* 3. Full Name

First Name

Middle Name

Last Name

What name do you prefer to be called?

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* 4. Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 5. Home Phone

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* 6. Business/Cell

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* 7. E-mail Address

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* 8. Date of Birth (MONTH/DAY/YEAR)

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* 9. County of Residence

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* 10. Name of your college if applicable

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* 11. Name of High School if currently enrolled

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* 12. Class(es) you are enrolled in if applicable

Class 1

Class 2

Class 3

Class 4

Class 5

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* 13. College Advisors Name or Internship Advisor:

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* 14. Area/s of interest

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* 15. Do you have reliable transportation?

Yes

Personal Expression (Required)
(Please answer the following based on your work with young children or your personal experiences which include interactions with children in your family, church, or community)

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* 16. What experiences have you had working with children in your personal or professional life? (What have been some of the challenges? What was most valuable about your experience? What did you enjoy most or find most rewarding and how does this relate to your desire to earn a degree in early childhood education?)

Criminal History

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* 17. Have you been convicted of any criminal offense by a civilian court or by military authorities within the last seven years?

Yes

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* 18. Have you been adjudicated or held responsible as a juvenile offender of any criminal offense?

Yes

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* 19. If you answered "YES" to any of the above questions, please explain in the space below; ( Please list the location, charge, date, and punishment. Conviction of a crime will not necessarily disqualify you from serving. Each instance and action will be considered in relation to the position for which you are applying. However, any intentional misrepresentation or omission will disqualify you. The conviction or substantiation of child abuse, child neglect, a violent crime, or a sexual crime will disqualify you from participation. Do not include minor traffic violations.

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* 20. Anticipated degree:

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* 21. Anticipated date of graduation: (Month/Day/Year)

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* 22. Please Indicate the highest l

High School Student

Early College Student

High School Diploma or GED

Community College/Technical School

Associate's Degree

Some college

Bachelor's Degree or Higher

Other (please specify)

Questions 23 & 24 are for Early Childhood Teachers Only

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* 23. Are you an active participant in T.E.A.CH.?

Yes

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* 24. Name of early childhood program where employed, if applicable:

For parent or guardian of applicants currently under 18 years of age:

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* 25. I have reviewed this application, and authorize my son/daughter/legal ward to apply to the WISEE program.

Signature

Date

Address

CERTIFICATION

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* 26. Your application must be certified with your signature at the end of this application.

By filling out the signature line at the end of this application you are certifying that all of the statements made in this application are true, correct, and complete, to the best of my knowledge, and are made in good faith. I understand that misinformation or omission of information could result in disqualification and/or termination from the WISEE program.

If accepted, I agree to abide by the rules and policies of the WISEE program. I understand that no representative of WISEE has any authority to enter into any agreement contrary to the rules and policies of Stokes Partnership for Children.

I understand that this application is not an employment contract.

Signature

Date