Individual Review Route ECTC

Individual Review Route ECTC

Early Childhood Teacher Credential

Individual Review Route

Application

Last Name: / First Name: / Middle Initial:
Alternate last name: / DOB:
Email Address:
Home Address:
City: / State: / Zip Code:
Home Phone: / Work Phone: / Cell Phone:
Do you currently have a CT Early Childhood Professional Registry account? Yes No
Registry #______
Current employer: / Employer Verification Form attached?
Yes No
How did you hear about the Early Childhood Teacher Credential Individual Review Process?
College Publicly Funded ECE Program CAEYC/OEC Website
Other Please Specify: ______

In order to meet Connecticut State and U.S. Federal reporting requirements, we are asking that you voluntarily provide the following information:

Gender, Race/Ethnic Background Data (Optional) – Check all that apply

Male / Female / American
Indian or Alaskan Native / Asian/Pacific Islander / Black/ African American Not of Hispanic Origin / Hispanic / White-Non Hispanic

Employment History

Teaching Experience- Please document your early childhood (preschool or infant/toddler) experience.

Ex. Teacher, Assistant Teacher, Teacher Aide, Family Home Provider

Current Employer (Program Name & Address):
Type of Setting:
(Ex. State Funded Program, Family Home Care) / Dates of Employment:
Current Position: / Age Group:
Previous Employer (Program Name & Address):
Type of Setting:
(Ex. State Funded Program, Family Home Care) / Dates of Employment:
Previous Position: / Age Group:
Previous Employer (Program Name & Address):
Type of Setting:
(Ex. State Funded Program, Family Home Care) / Dates of Employment:
Previous Position: / Age Group:

Employment Verification Form

Please send your documentation to:

Connecticut Association for the Education of Young Children

615 West Johnson, Suite 202

Cheshire, CT 06410

Attn: ECTC IRR Coordinator

Email:

Fax: (203) 439-0616

This section to be completed by IRR ECTC candidate

Candidate’ Name: ______

Current Address: ______

______

Program Name: ______

Program Address: ______Telephone: ______

City/Town: ______State: ______Zip Code: ______

Type of program:

____ State Funded* ____ Licensed Center ____ Licensed exempt program

*SR, CDC, SHS, PDG

Position: ______

Role/Responsibilities: ______

______

Dates of employment: ____/______to ____/______(If still employed, enter today’s date).

This section to be completed by supervisor providing verification of employment

I attest the above information submitted by the candidate to be true and accurate:

Program Name: ______

Program Address: ______Telephone: ______

City/Town: ______State: ______Zip Code: ______

Supervisor Name: ______

Supervisor Title: ______

Supervisor Signature: ______Date: ______

Growing as a Professional

The sixth ECTC competency standard is Growing as a Professional. The Individual Review Route process will provide all candidates the opportunity to grow as an early childhood educator. This section of the application will provide a candidate the opportunity to demonstrate how they met this competency standard through providing the documents listed below:

1. Writing sample on page 6 of application

2. List of membership(s) held in professional early childhood organization

3. List of activities benefiting the field of early care and education

4. Training certificates of professional development activities completed in the past 2 years

Please label and attach all supporting documents to the application.

Writing Sample

Include with your application a Writing Sample in the space below or as an attachment with a minimum of 250 words.

Please describe current trends and challenges in the field of early care and education and how those affect your current and future work in an early childhood classroom.

Candidate Document Checklist

APPLICATION
ASSESSMENT / YES / NO / DATE / CAEYC Office Use Only:
Are you currently employed as a teacher in a state funded early childhood program serving children birth to 5?
If you are not working in a state funded early childhood program, do you plan to seek a position as a teacher in a state funded program by July 2017?
Are you currently enrolled in the Connecticut Early Childhood Professional Registry?
Registry ID #: ______
Have you sent all diplomas, official and/or unofficial transcripts to the CT Early Childhood Professional Registry?
Have you attached a copy of your CT Early Childhood Professional Registry Education and Training Report to this application?
This can be found after logging in to the account, under My Tools and Settings.
Have you attached the Employment Verification Form completed by previous and/ or current employers documenting your early childhood teaching experience?
Have you completed and attached the 250 word minimum Writing Sample outlining how current trends and challenges in the field affect your current experiences in an early learning classroom to the application?
Have you completed and attached the supporting documentation for Standard 6 to this application?

SIGNATURE REQUIRED: By signing or typing my name on the signature line below, I certify the statements made on this application form and its attachments are true and complete to the best of my knowledge and are made in good faith. I understand if I knowingly make any misstatement of fact, I am subject to disqualification and dismissal and to such other penalties as may be prescribed by law or personnel regulations. All statements made on this application, including employment information, are subject to verification as a condition of this process.

Note to IRR ECTC candidate: A typed name will substitute for a handwritten signature.

Applicant Signature: ______Date: ______