CDA Application – Early Childhood Consumer Education and Technical Assistance Center

Name *

First

Last

Street Address *

City, State, Zip Code *

County of Residence *

Phone Number *

Email *

Date of Birth *

Last four of social *

Child Care Facility 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? *

Yes
No

Do you work for a child care center for at least 20 hours per week? *

Yes
No
Third Choice

Which CDA are you looking to obtain? *

Infant and Toddler CDA
Preschool CDA
Family Child Care CDA
Home Visitor CDA

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?

Tuesday
Thursday

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 withdrawl to be eligible for this option