Please Email Completed Form to Or

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Application: CDA-to-Associate’s Degree ECE Apprenticeship:

Please email completed form to or

fax to 215-563-4683. Call 215-568-2220 with any questions.

CONTACT INFORMATION
Name (First, Middle, Last) / DOB (MM/DD/YYYY) / The last 4 digits of your SSN:
XXX - XX - ______
Home Address / City / State / Zip
E-Mail
Home Phone: (______) ______- ______/ Cell Phone: (______) ______- ______
DEMOGRAPHIC INFORMATION
Gender (circle one)
Male Female Prefer not to respond / Race (circle one)
Caucasian Pacific Islander Af. Am/Black Asian Native American Multi-Racial Hispanic Other Prefer not to respond
Sexual Orientation (circle one)
LGBTI Not LGBTI Prefer not to respond
EMERGENCY CONTACT INFORMATION
Name: / Relation to you: / Contact Number
(______) ______-______
EMPLOYMENTSTATUS
Employer / Job Title / Hourly Wage / Work Phone Number
(______) ______-______
EDUCATION
Do you have a high school diploma or GED?
Yes No / Do you have your CDA credential?
Yes No
If you have attended any college or post high school education/training, please tell us where you attended.
Please be certain to note any credits you have received from Community College of Philadelphia (CCP).
IF YES, PLEASE ATTACH TRANSCRIPT (Official or unofficial) / What school(s)?
1.
2.
3. / Did you complete?
Yes No Still attending
Yes No Still attending
Yes No Still attending
Major/Course of Study
1.
2.
3. / Start Date (mm/yyyy) / End Date (mm/yyyy) / Degree/Certificate/Credential Obtained
Name: ______Date: ______

ESSAY (At least 3 paragraphs)

Please share some information about yourself to help us understand why you are interested in the CDA-to-Associate’s Degree ECE Apprenticeship. Please include:

(1) Your career goals, and how this program will help you achieve them
(2) Three challenges you will need to overcome to succeed in a 24-month Associate’s Degree program
(3) How will you address each of these challenges?

This essay is required for all applicants. Please just do your best.

Revised9/13/2018, Effective 9/122016