Form Dcdee 0061 Preservice Requirements For Administrator Of A Child Care Center
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3DCDEE 0061
P
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A
C
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RESERVICE
EQUIREMENTS FOR
DMINISTRATOR OF A
HILD
ARE
ENTER
02/13
Name of Center __________________________________________________ ID# _________________________
Name of Legal Operator/Owner __________________________________________________________________
On-Site
Off-Site
Name of Administrator________________________________________________________________________
Mailing Address __________________________ _______________________________ ______ ___________
Date of Birth ______/_______/_________
Home Phone (____)_____-_________
Work Phone (____)_____-___________ Fax__________________
EDUCATIONAL BACKGROUND
High School Diploma/GED: Date Received _________School _________________________________ City_____________________
YES NO Date Received _________School _________________________
NC Early Childhood Credential/Equivalent:
YES NO Date Received _________School _________________________
NC Administration Credential/Equivalent:
Level I II III
Child Development Associate: YES NO Date Received _________Organization_______________________________________
Diplomas/Degrees: AA/AS
BA/BS
MA/MS
Ed.D/Ph.D. Major/Minor:____________________________
Date Received _________School ________________________________ Hrs. in Early Childhood/Related Area____________
CHILD CARE EXPERIENCE
Employer
Months Employed
Duties
________________________________
_______________
_____________________________________________
________________________________
_______________
_____________________________________________
ADMINISTRATIVE EXPERIENCE
Employer
Months Employed
Duties
________________________________
_______________
_____________________________________________
________________________________
_______________
_____________________________________________
ADMINISTRATIVE COURSEWORK
Course Title:_________________________ Date ________ Received Tested Out School ________________________________
Course Title:_________________________ Date ________ Received Tested Out School________________________________
I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorize investigation of
statements made on this form and understand that providing false information may be grounds for denying this application.
Signature of On-Site Administrator
Date Signed
I have reviewed the above information and certify its accuracy.
Signature of Legal Operator/Owner
Date Signed
Requirements Met
(DCDEE CONSULTANT USE ONLY)
21 Yrs. + HS/GED
NC Administration Credential
Date of Employment
Date of Termination
Highest Grade: ________________
Yes No
________/________/________
________/________/________
Other Qualifications Met
1 Yr. Administrative Experience
Credentials
2 Yrs. Child Care Experience
NC Early Childhood Credential Yes No
NCECC+ 1 yr child care exper.
Enrolled in Admin. Coursework
Completed or tested out of
Date received:____________
CDA
Community College
Admin. Coursework
Degree w/ Semester Hrs.
NC Administration Credential Yes No
Level: I II III
Date received:____________
Reviewed by:______________________________________Date:_________________
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