North Carolina Early Childhood Association2011 Virtual Membership Application for Certified Early Educators Survey

1

[Please give us your name and address. Under "company", please put the name of the early childhood program in which you work.]

[Please give us your name and address. Under "company", please put the name of the early childhood program in which you work.] Name
Company
Address 1
Address 2
City
State
Zip
Email Address

2

[Please check the circle that best describes your current employer, listed in the "company" line above.]

[Please check the circle that best describes your current employer, listed in the "company" line above.] Private, tax-paying center

Private, nonprofit center

Church/synagogue/religious sponsored center

Employer operated center

County/state/federally operated center

Community college or university child care center

Public school operated center or classroom

Head Start program

Family child care home

Child care resource & referral or Smart Start agency

Community college/university (not in a child care center)

State/county government (not in a child care center)

Parent

Advocacy organization

3

[What county do you live in?]

4

[Home Telephone Number]

5

[Work Telephone Number]

6

[Email Address]

7

[What is your current job title?]

8

What is your Early Educator Certification Number?

9

[Please check the circle which describes the star rating of the program in which you work, if applicable.]

[Please check the circle which describes the star rating of the program in which you work, if applicable.] 5-star center

5-star home

4-star center

4-star home

3-star center

3-star home

2-star center

2-star home

1-star center

1-star home

GS-110 center

Unlicensed pre-k or More at Four program

I do not work in an early care and education program

Other, please specify