Form Dcdee.0162 Lead Teacher Equivalency Form For Approved High School Coursework
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1
2NC Division of Child Development and Early Education
DCDEE Use Only
Lead Teacher Equivalency Form for Approved High School
COI Only ________________
Coursework (DCDEE.0162)
– See Instruction Page – Please print or type.
SSN (Last 4 Digits Only):
Date of Birth (mm/dd/yy):
–
A) Applicant Information
Fill in every blank or write N/A
/
/
Check here if requesting:
Status Letter Only
First Name (No Nicknames):
Legal Last Name:
Previous Names:
Home Mailing Address (Include Apartment or Lot # if applicable):
City (No Abbreviations):
State:
Zip Code:
Home Phone #:
Cell Phone #:
County of Residence:
(
)
(
)
Email Address:
Date Employed at Facility:
County of Employment:
B) Facility Information
/
/
Check here if not working at a child care facility
Facility ID # (on license):
Name of Facility:
Facility Phone #:
(
)
Facility Address:
City:
State:
Zip Code:
Current Position: (check one of the positions below)
Administrator
Assistant Director
Lead Teacher
Teacher
FCCH Provider
Group Leader
Program Coordinator
Owner
Other
___________________________________________________
Check box below if the facility where you are currently employed is either a Developmental Day or NCPreK program:
Developmental Day Facility:
Age Range:
Birth – 3 years
3 years & older
School-Age
NCPreK Facility:
C) Educational Background – Copy of high school diploma and NC Community College official transcript must be
attached to form. Photocopies of transcripts, student or internet copies and grade reports are NOT accepted. C
heck here
if the NC Community College is mailing your official transcript separately.
High School Information (Required):
HS Diploma
Currently Enrolled
None
D) Educational Qualification
If you meet the requirements for high school equivalency, you are eligible to be qualified for Lead
–
Teacher, Teacher and Family Child Care Home Provider. Please check the child care position(s) for which you request to be qualified.
Lead Teacher
Teacher
FCCH Provider
NOTE: You must fill out the entire form and attach a copy of your high school diploma and your official transcript(s) from
a NC Community College or the form will be returned to you unprocessed.
The form must also be signed and dated by you, the applicant, or it will be returned to you unprocessed.
I attest to the accuracy of the above information. I understand that completing the Early Childhood Education I & II
coursework in high school will result in EQUIVALENCY STATUS ONLY and that I will not be eligible to earn the NC Early
Childhood Credential Certificate. I also understand that approval of my equivalency status is conditional upon, but not
limited to, successful completion of the coursework resulting in curriculum credit at a NC Community College.
Signature ________________________________________________
Date ________________________
Applicant should retain a copy of this form and any attached documentation for his/her records.
DCDEE.0162_Revised August 2015
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