Our House CDA Application 2024

First Name *

Last Name *

Address *

Address 2

City *

State/Province *

Zip/Postal Code *

Phone *

Personal Email Address (that you check daily) Click here if you need a free email address *

Are you currently living in a Housing Program? *

Yes

No

If you answered Yes to the Housing Program Question please list the name of the program and the name of your case manager:

If you answered No to the Housing Program Question please list your list full address including the county where you reside:

Education (All applicants must have a completed a GED Program or have a High School Diploma) *

	High School/Ged	Universty/College Undergraduate	Trade/Business or Correspondence School
Name and Location of School	High School/Ged	Universty/College Undergraduate	Trade/Business or Correspondence School
Years Attended	High School/Ged	Universty/College Undergraduate	Trade/Business or Correspondence School
Did you Graduate?	High School/Ged	Universty/College Undergraduate	Trade/Business or Correspondence School
Years Completed	High School/Ged	Universty/College Undergraduate	Trade/Business or Correspondence School

Upload proof of completion of High School/GED, University/College Degree, Trade Certificate *

Employment History *

	Employer #1	Employer #2	Employer #3
Employer (Name of Organization)	Employer #1	Employer #2	Employer #3
Address	Employer #1	Employer #2	Employer #3
Job Title/Duties	Employer #1	Employer #2	Employer #3
Address	Employer #1	Employer #2	Employer #3
Phone	Employer #1	Employer #2	Employer #3
Starting Pay/Ending Pay	Employer #1	Employer #2	Employer #3
Dates you were employed:	Employer #1	Employer #2	Employer #3
Reason for Leaving	Employer #1	Employer #2	Employer #3

Demographic Information

	(Demograpic Information has no impact on program admittance or program status)
Gender	(Demograpic Information has no impact on program admittance or program status)
Primary Language	(Demograpic Information has no impact on program admittance or program status)
Refugee (Y/N)	(Demograpic Information has no impact on program admittance or program status)
Immigrant (Y/N)	(Demograpic Information has no impact on program admittance or program status)
Race	(Demograpic Information has no impact on program admittance or program status)
Health Insurance (Y/N)	(Demograpic Information has no impact on program admittance or program status)
Yearly and Annual Income	(Demograpic Information has no impact on program admittance or program status)
Where do you typically access health services?	(Demograpic Information has no impact on program admittance or program status)
Homeless (Y/N)	(Demograpic Information has no impact on program admittance or program status)

Do you have a child (birth-age 5) that you will require childcare services for? *

References: Please provide names and contact information below for at least three people who are not relatives and able to make statements about your prior work experience. (Ex: work supervisor, teacher, co-worker, case manager) *

	Reference #1	Reference #2	Reference #2
Name	Reference #1	Reference #2	Reference #2
Occupation	Reference #1	Reference #2	Reference #2
Address	Reference #1	Reference #2	Reference #2
Relationship (how do you know this person)	Reference #1	Reference #2	Reference #2
Phone Number	Reference #1	Reference #2	Reference #2
Email Address	Reference #1	Reference #2	Reference #2
Years you have known them	Reference #1	Reference #2	Reference #2

Have you been vaccinated in against COVID-19. Please note vaccination is not currently a requirement to apply for the program however it could be a requirement for internship assignments and employment opportunities. *

If you answered YES to vaccination question, please upload a copy of your vaccination card here:

Technology *

	Yes/No
Do you have access to the internet?	Yes/No
Do you have access to a computer?	Yes/No
Do you feel comfortable using Microsoft Word with out assistance?	Yes/No
Do you feel comfortable using the internet to do research?	Yes/No

What are your professional and personal goals? *

Describe what you know about the Child Development Associate (CDA) Credential and explain why you decided to apply for this training? *

Describe your current level of experience working with children (Other than your own): *

Describe what you think will be positive AND challenging about working with children all day: *

Once you have successfully completed the training hours (120), internship hours (480) and taken the exam, how do you plan to use this credential professionally? *

By selecting yes below, you acknowledge and confirm understanding that to maintain a CDA credential you must do the following: 1. Submit 45 state approved training hours to the Council for Professional Recognition for renewal as required based on the expiration date as listed on your credential. 2. You must renew your CDA credential before it expires by submitting a completed application with supporting documents during your specified renewal window. 3. You may submit your CDA renewal application up to 6 months before your credential expires. 4. You can only renew in the setting of your original credential. 5. If the CDA credential is not renewed and expires, the credential is no longer valid. You may be required to reapply, complete training and re-test. *

Please sign *

clear

What is your birthdate? *