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Partners
Mentors/Journeypersons Information Form

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?



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