CDA Application

Name *

First

Last

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

County in which you reside *

Phone *

Email *

Date of Birth *

Last four of Social *

Child Care Program that Participant works at. *

Which Program are you applying for? *

• CCCC
• CDA

Are you at least 18 years of age? *

• Yes
• No

Do you hold a high school diploma/ GED? *

• Yes
• No
• Third Choice

Are you applying for the Kids Now Scholarship? *

• Yes
• No

Who is your CCA Professional Development Coach?

If we need to have multiple classes which day would you prefer? * *

• Monday's @6:30 pm. est.
• Wednesday's @6:30 pm. est
• Friday's @ 9:00 am. est
• Saturday @9:00 am. est

Have you been approved the Kids Now Scholarship? *

• Yes
• No
• Not Sure

If not, It is $500.00 for each 60 hours of credit. The total for the CDA program for ECCTC is $1,000.00. We have three payment options. Please choose which option best fits yours needs.

• Option 1: Pay full amount of $1,000.00 to ECCTC in full for the CDA courses.
• Option 2: Pay $500.00 for each 60 hours at the beginning of each semester.
• Option 3: Pay $200.00 at the beginning of the course and pay $20.00 per session. This will have to be automatic withdrawal to be eligible for this option

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