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Family and Social Services Administration

Office of Early Childhood and Out-of-School Learning Home > Provider Resources > Professional Development > Online Child Care Learning (CCL) > Childcare Learning > Mentor Information > Apply to become a mentor! Apply to become a mentor!

Steps to Formal Application - Mentors

Date
Name
Female Male
Social Security Number
Birth Date
Address
City
State
Zip
County
Phone (home)
Phone (work)
E-mail
Fax

Section 1: Childcare Employment Status

  • What is your job title?
  • How many hours do you work per week?
  • Date of employment at current workplace?
  • What is your current hourly rate of pay?
  • Do you work in a classroom?
If yes, what age group?
and what hours?
  • Do you own a Family Child Care Home?
If yes, how many years have you worked
in a child care center or a
family child care home?

Section 2: Educational Background

  • High School
Yes No
  • Dates Attended
  • Diploma (select one)
Yes No
  • GED (select one)
Yes No
Please leave BLANK if not applicable
College/University




Dates Attended




Major(s)




Degree or Credit Hours




Section 3: Family Structure (this information will be used for demographic purposes only)

How many people live in your household?
List everyone in your household and their relationship to you. (Include yourself)
Name
Relationship
Name
Relationship
Name
Relationship
Name
Relationship

Section 4: Ethnicity: Do you consider yourself . . . ?

White/European American
Black/African American
Hispanic/Latino/Latina
Asian/Pacific Islander
Bi-racial
American Indian (tribe)
Other

Section 5: Child Care Center / Home Information

  • Name of Child Care Center / Home
  • Name of Director
  • License/Registration Number
  • License/Registration Capacity
  • Center Address and County
  • Center E-mail:
Center Auspice: (Check all that apply)
Profit Center
Head Start
Public School
Non-Profit
Public
Registered Ministry

Section 6: Why do you want to be an Early Childhood Mentor?



Childcare Learning Navigation