Infant Toddler CDA $425 Reimbursement*** Infant Toddler CDA $425 Payable to CDA Council*

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1 UTAH REGISTRY FOR PROFESSIONAL DEVELOPMENT SCHOLARSHIP APPLICATION (Use through 7/1/2017 5/31/2018) SECTION 1: SCHOLARSHIP SELECTION Please select type of scholarship you are requesting: (CHOOSE ONE) CDA: Preschool CDA $425 Reimbursement*** Preschool CDA $425 Payable to CDA Council* Infant Toddler CDA $425 Reimbursement*** Infant Toddler CDA $425 Payable to CDA Council* Family Child Care CDA $425 Reimbursement*** Family Child Care CDA $425 Payable to CDA Council* College Level Early Childhood Course Reimbursement Maximum of $150 Face to Face National Administrator s Credential (NAC) Reimbursement Maximum of $150 Community Based Career Ladder class that exceeds $200 in cost Reimbursement Maximum of $150 Demonstrated Competency Observation Fee by CCPDI Approved Observer Reimbursement to Observer Maximum $100 *CDA Checks made payable to the council must be submitted to the council within 30 days of receipt or they will be void ***All Reimbursements require an IRS W9 form and Proof of Payment made by the individual requesting the scholarship*** All scholarships require that the individual be working at least 15 hours a week in a paid position with children. The Family Child Care and Infant Toddler CDA scholarship requires that the program employed in be regulated with Utah Child Care Licensing. (unless program is located on a Native American Reservation) Only one scholarship per person per fiscal year. If a second CDA scholarship is needed for a provider, approval must be obtained from their local CAC Agency and OCC even if the scholarship is being requested in a new fiscal year. SECTION 2: CANDIDATE IDENTIFICATION DATE OF BIRTH IF APPLYING FOR REIMBURSEMENT PLEASE / / FILL OUT ATTACHED W9 FORM LAST NAME (AS IT APPEARS ON LAST YEARS TAXES) FIRST NAME MIDDLE NAME MYCDA ID# STREET ADDRESS CITY COUNTY ZIP CODE HOME PHONE CELL PHONE E MAIL ADDRESS SECTION 3: PROGRAM IDENTIFICATION PROGRAM NAME (LEGAL NAME OF PROGRAM) PROGRAMTELEPHONE STREET ADDRESS CITY COUNTY ZIP CODE CANDIDATE POSITION START DATE / / HOURS WORKED PER WEEK (MINIMUM OF 15) NUMBER OF CHILDREN ENROLLED IN PROGRAM AGES OF CHILDREN YOU WORK DIRECTLY WITH INFANTS 1YR OLDS 2YR OLDS 3YR OLDS 4YR OLDS 5YR OLDS KINDERGARTEN SCHOOL AGE SECTION 4: EMPLOYMENT VERIFICATION CANDIDATES WHO ARE NOT THE REGISTERED OWNER OR APPROVED AUTHORITY OF THE PROGRAM IDENTIFIED, MUST HAVE THEIR SUPERVISOR COMPLETE THIS SECTION SUPERVISOR NAME SUPERVISOR TITLE CONTACT NUMBER I HAVE REVIEWED THE CANDIDATE AND PROGRAM IDENTIFICATION LISTED BY MY EMPLOYEE ON THIS FORM AND CERTIFY THIS INFORMATION TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND AND WILL AUTHORIZE MY PROGRAM TO PARTICIPATE IN ANY RESEARCH PROJECTS OR OBSERVATIONS AT THE REQUEST OF THE OFFICE OF CHILDCARE. I UNDERSTAND I CAN AND WILL BE PENALIZED BY LAW IF I COMMIT PERJURY BY PURPOSELY CONFIRMING ANY FALSE INFORMATION ON THIS FORM. I ALSO UNDERSTAND I MAY LOSE MY OWN PRIVILEGE TO PARTICIPATE IN FUTURE CAREER LADDER AND DEPT OF WORKFORCE SERVICES GRANT PROGRAMS. SUPERVISOR SIGNATURE DATE MAKE SURE YOU FILL OUT PAGE 2 CCPDI Office Use Only Scholarship Type Index # Staff

2 SECTION 5: ELIGIBILITY FOR ALL SCHOLARSHIPS: I work at least 15 hours a week in paid position with children. I have checked and my program does not offer assistance and I am unaware of any other funding available to pay the cost of this. FOR CDA SCHOLARSHIPS: If I am requesting the scholarship for a Family Child Care or Infant Toddler CDA then I work in a program regulated by Utah Child Care Licensing. (unless program is located on a Native American Reservation) I agree to submit a copy of my CDA to the Utah Registry for Professional Development. I agree to schedule & complete my assessment visit within 90 days of the CDA specialist contacting me. Please initial the following: Ready to submit CDA Application Completed Required 120 hours of training in 8 CDA areas Completed required 480 hours of working with children Completed professional portfolio Collected required completed family questionnaires I am requesting for the $425 CDA fee to be issued in the form of a check made payable to the CDA Council that URPD will mail directly to the CDA Council in my behalf. OR I am requesting reimbursement of the $425 CDA fee and have included my proof of payment from my personal funds and the completed IRS Form W9 with this application. FOR DEMONSTRATED COMPETENCY SCHOLARSHIP: I am applying for the Demonstrated Competency Observation Fee. This fee is payable directly to a CCPDI Approved Observer. Please list the Approved Observer s Name. FOR All OTHER SCHOLARSHIPS: I am requesting reimbursement of up to $150 of the cost and have included my proof of payment from my personal funds, proof of completion of course and the completed IRS Form W9 with this application. SECTION 6: CANDIDATE CERTIFICATION I, THE CANDIDATE, CERTIFY THAT THE INFORMATION I HAVE GIVEN ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND MY INFORMATION WILL BE ENTERED IN UTAH S EC/SA WORKFORCE REGISTRY. UPON REQUEST, I AGREE TO PARTICIPATE IN ANY RESEARCH PROJECTS OR OBSERVATIONS AT THE REQUEST OF THE OFFICE OF CHILDCARE. I CAN BE PENALIZED BY LAW IF I COMMIT PERJURY BY PURPOSELY PROVIDING FALSE INFORMATION ON THIS APPLICATION, AND MAY BE REQUIRED TO RETURN SCHOLARSHIP FUNDS RECEIVED BY PROVIDING FALSE INFORMATION AND/OR BE SUBJECT TO FINES. I ALSO UNDERSTAND I MAY LOSE MY PRIVILEGE TO PARTICIPATE IN FUTURE CAREER LADDER AND DEPT OF WORKFORCE SERVICES GRANT PROGRAMS. CANDIDATE SIGNATURE DATE THINGS TO REMEMBER: ANY INCOMPLETE APPLICATIONS WILL BE RETURNED TO APPLICANT. APPLICATION MUST BE THE ORIGINAL DOCUMENT, CONTAINING THE ORIGINAL SIGNATURES OF APPLICANT AND EMPLOYER. FAXED OR ED APPLICATIONS WILL NOT BE ACCEPTED. APPLICATIONS MUST BE SUBMITTED ON 8½ x 11 WHITE PAPER AND COMPLETED IN INK. A SOCIAL SECURITY NUMBER MUST BE INCLUDED ON THE W9 IF APPLYING FOR A REIMBURSEMENT. THE NAME ON THE APPLICATION MUST BE THE LEGAL NAME PRINTED ON YOUR SS CARD. ALL APPLICATIONS MUST BE POST MARKED BY MAY 31, QUESTIONS: IF YOU HAVE QUESTIONS ABOUT THE UTAH PROFESSIONAL DEVELOPMENT SYSTEM OR ABOUT COMPLETING THIS APPLICATION, PLEASE CONTACT THE UTAH REGISTRY FOR PROFESSIONAL DEVELOPMENT (URPD) AT MAIL APPLICATION TO: URPD 6515 OLD MAIN HILL LOGAN, UT ***All Applications Must Be Post Marked by May 31, 2018***

3 ATTENTION FOR CDA SCHOLARSHIPS ONLY STEP 1: When you are selecting your payment type during the online application process, make sure to select the check or money order option. STEP 2: On the payment information screen that asks for check # you can enter 1234 and the name on the check will appear as Utah State University. SAMPLE of cover letter to be included with scholarship application. STEP 3: When the payment submission screen appears click on the PRINT COVER LETTER and mail cover letter with this application. If you are unable to print, please contact URPD

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