ACDS - Mentors/Journeyperson Information Form

Partners

Mentors/Journeypersons Information Form

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Personal Information
County	Social Security #
Gender	Male Female
First Name
Maiden Name
Last Name
Home Address
City
State
Zip
Home Phone
E-mail

Education and Training
Check all that apply before taking ACDS classes.	GED/High School Some College Credit Associates Degree Vocational Classes Junior/Business College 4-year College Degree CDA Other

Age	18-25 26-35 36-45 46 and up

Information while taking ACDS classes
Program/Sponsor Registration # with United States Dept. of Labor/Bureau of Apprenticeship Training.

Program and city where employed while an ACDS student

Family Provider/Mentor

Supervisor while an ACDS student

Job title while an ACDS student	Teacher Teacher's Aide/Assistant Substitute Teacher Family Provider Home Visitor	Lead Teacher Co-Teacher Substitute Aide Director Other

Salary/Hourly wage before taking ACDS class

Date began ACDS

Date completed ACDS classes

Received Dept. of Labor Certificate	Yes No

Location of ACDS classes (county/building)
Please list instructor's name beside each semester.
	Semester 1
	Semester 2
	Semester 3
	Semester 4

Current Work
Current program where you are employed
Address
City
State
Zip
Current Work Phone
Current Work Fax Number

Current job title where you are employed	Teacher Teacher's Aide/Assistant Substitute Aide Director Home Visitor Trainer	Lead Teacher Co-Teacher Substitute Teacher Family Provider College Professor Other

Current Highest Education Level	GED/High School Some College Credit Associates Degree Vocational Classes	Junior/Business College 4-year College Degree CDA Other

Years of paid experience in Early Childhood	1-5 5-10 11 or more

Ages of children/adults currently working with	Infants/Toddlers Preschool School-Age

Registered on Career Pathway:	Yes No
Career Pathway Level

Pay increase since completion of ACDS (check the box that most applies to you)	Hourly Pay No increase Up - .05 .06 - .10 .11 - .24 Salary No increase 1% - 5% 6% - 10% 11% and up	.25 - .50 .51 - .75 .76 - .99 $1.00 or more

What affect has ACDS had on your life?

Suggestions?