Start Bright Scholarship Form - Child Care Council

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Applicant Information

Full Name*

First Middle Last

Address*

Street Address Apartment/Unit # City State ZIP Code

Phone*

Email*

Child Care Program Information

Program Name*

Modality of Care*

Family Day Care

Group Family Day Care

Day Care Center

Legally Exempt

School-Age Child Care

Other

Director/Owner Name*

First Last

Phone*

Email*

Address*

Street Address Apt./Unit/Suite # City State ZIP Code

Position*

Length of Time in Position*

Verification of Eligibility

The applicant’s household adjusted gross income as reported on the most recent IRS Form 1040 must fall within the ranges on the income chart below. Child Care Council, Inc. reserves the right to seek additional verification that the income documentation submitted is accurate and authentic.

Family Size	100%	75% of amount requested
1	$0 – $42,789	$42,790 – $57,052
2	$0 – $55,955	$55,956 – $74,607
3	$0 – $69,121	$69,122 – $92,161
4	$0 – $82,287	$82,288 – $109,716
5	$0 – $95,453	$95,454 – $127,271
6	$0 – $108,619	108,620 – $144,825

Confirmation*

I confirm that I meet the income eligibility requirements above.

Have you applied for another scholarship to cover the cost of our course(s)?*

Yes

Which scholarship have you applied for?

EIP

VOICE/CSEA CDA Professional Development Program (only FDC or GFDC provider is eligible)

Other

Which scholarship are you applying for today?*

Child Development Associate Course Scholarship

General Course Scholarship

Child Development Associate Course Information

If you will use the funds to cover the registration fee and/or CDA Module cost(s), please complete the following information.

CDA Course #*

Trainer Name*

Start Date*

End Date*

Are you applying to cover the registration fee cost?*

The course registration fee is $125.

Yes

Registration fee balance:

Total amount requested:

Are you applying to cover the cost of one or more CDA modules?*

The cost of each module is $625.

Yes

Please specify the module(s) you wish to cover.

CDA Module 1

CDA Module 2

CDA Module 3

CDA Module 4

Online CDA with CCC ($199)

Total amount requested:

General Course Information

If you will use the funds to cover a registration fee and/or cost of a course, please provide the course information below. Use the + buttons to add title, start date, end date, and cost fields for each additional course.

Course Title*

Start Date*

End Date*

Course Cost*

Total amount requested:*

The maximum amount that may be approved is $400.00 per person, per calendar year.

Required Information

Please submit the following documentation with your application.

Cover Letter*

Explain the reason(s) why the participant is unable to use other scholarship providers, such as EIP, to cover the cost or balance of the CDA Module(s), registration fee, and/or other course cost(s) and should include how the course will support the participant in the early childhood field.

Proof of Employment*

If the participant is an employee at a Day Care Center, School-Age Child Care, Family Day Care or Group Family Day Care program, the application must include income information from the employer in the form of a letter on the day care’s letterhead or a copy of a pay stub from the employer received within the past 3 months. On-Site providers will be required to provide a copy of the child care Registration or License. Legally Exempt providers will be required to submit a copy of the Enrollment Letter.

Accepted file types: pdf, doc, docx, jpg, jpeg, Max. file size: 5 MB.

Copy of Form 1040 from*

Applicants must qualify based on the EIP income guidelines. Scholarship eligibility is based on current employment and the applicant’s household income.

Accepted file types: pdf, doc, docx, jpg, jpeg, Max. file size: 5 MB.

Approval from Trainer (CDA only)

If the participant is applying for funds to cover a current CDA course, a reference from the trainer is required. Please provide the course number and trainer’s name in the field below.

Submission

Certification*

I certify that my answers are true and complete to the best of my knowledge.

If this application contains false or misleading information, I understand that such information in my application may result in an application denial or required reimbursement of any scholarship funds received.

Signature*

Type your full name in the box below to serve as your signature.

Date*

Month

Day

Year

Comments

This field is for validation purposes and should be left unchanged.

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