Application is not complete until the final signature is completed at the end of this application. 

High school students complete questions 1-11
Early Childhood Teachers complete all questions

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* 1. Application Date

Date
 General Information

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* 2. Full Name

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* 3. Address

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* 4. Home Phone

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* 5. Business/Cell

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* 6. E-mail Address

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* 7. Date of Birth (MONTH/DAY/YEAR)

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* 8. County of Residence

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* 9. Name of your college/school

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* 10. Class(es) you are enrolled in

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* 11. College Advisors Name

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* 12. Area/s of interest

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* 13. Do you have reliable transportation? 

Personal Expression (Required)
(Please answer the following based on your work with young children or your personal experiences which include interactions with children in your family, church, or community)

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* 14. What experiences have you had working with children in your personal or professional life? (What have been some of the challenges? What was most valuable about your experience? What did you enjoy most or find most rewarding and how does this relate to your desire to earn a degree in early childhood education?)

Criminal History

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* 15. Have you been convicted of any criminal offense by a civilian court or by military authorities within the last seven years? 

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* 16. Have you been adjudicated or held responsible as a juvenile offender of any criminal offense?

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* 17. If you answered "YES" to any of the above questions, please explain in the space below; ( Please list the location, charge, date, and punishment. Conviction of a crime will not necessarily disqualify you from serving. Each instance and action will be considered in relation to the position for which you are applying. However, any intentional misrepresentation or omission will disqualify you. The conviction or substantiation of child abuse, child neglect, a violent crime, or a sexual crime will disqualify you from participation. Do not include minor traffic violations.  

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* 18. Are you currently a Stokes County resident or individual working in a Stokes County early childhood program (serving children birth to five and not yet in kindergarten) who are enrolled in at least one 3 credit hour college level course that meets the requirements for a degree in early childhood education with the goal to obtain an Early Childhood Education Associates degree or higher? 

If you answered yes to the above question, please complete the following:

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* 19. Are you an active participant in T.E.A.CH.? 

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* 20. Name of early childhood program where employed, if applicable:

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* 21. Anticipated degree:

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* 22. Anticipated date of graduation: (Month/Day/Year)

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* 23. Please indicate the highest level of education you have completed (check only one)

For parent or guardian of applicants currently under 18 years of age:

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* 24. I have reviewed this application, and authorize my son/daughter/legal ward to apply to the WISEE program.

CERTIFICATION

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* 25. Your application must be certified with your signature at the end of this application. 

By filling out the signature line at the end of this application you are certifying that all of the statements made in this application are true, correct, and complete, to the best of my knowledge, and are made in good faith.  I understand that misinformation or omission of information could result in disqualification and/or termination from the WISEE program. 

If accepted, I agree to abide by the rules and policies of the WISEE program.  I understand that no representative of WISEE has any authority to enter into any agreement contrary to the rules and policies of Stokes Partnership for Children.

 

I understand that this application is not an employment contract.

0 of 25 answered
 

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