Section I: Applicant Information
HOME CONTACT INFORMATION
WORK CONTACT INFORMATION
Select Job Title* Center/Director/Administrator Center Teaching Staff Child Care Center/Preschool Director/Admin. College Center Director/Administrator College Center Teaching Staff Family Child Care Director/Owner Family Child Care Assistant HS/EHS Director/Supervisor HS/EHS Home Visitor HS/EHS Classroom Teacher HS/EHS Administrator HS/EHS Disability Specialist HS/EHS Specialist PITC PQ Trainer PITC Regional Coordinator Consultant/Trainer Teen Parent/ROP/High School Resource & Referral Agency College Instructors Early Start Funded Family Resource Center Family Leader Early Intervention/Special Education - Other if other specify *required
EVENT YOU WISH TO ATTEND
Select ONE Desired Event* *required field
APPLICATION QUESTIONS
1. What degrees, professional certification, or credentials do you currently hold?* *required field
2. What years did you attend the four PITC modules?* *required field
3. In what settings have you offered PITC/early childhood trainings?* *required field
4. Briefly describe the three most recent early childhood trainings you have conducted: (indicate if the training was specific to infant/toddler and the content, audience, format)* *required field
5. In what settings do you envision offering trainings which incorporate information on infants/toddlers with special needs? (Do you regularly train for PITC Partners for Quality?)* *required field
6. What are your hopes for this Institute?* *required field
7. Are there specific questions or issues in the area of special needs or disability you have encountered in training situations that you hope you will be able to address after this training?* *required field
8. What barriers to including infants and toddlers with disabilities in caregiving settings have come up during training and your other work with early childhood providers?* *required field
9. Have you ever co-trained on PITC content with a partner...with a partner with special needs background?* *required field
10. What else would you like to share about your interest in this Institute or future training ideas?* *required field
Section II: Agreement to Complete Certification & Provide Training
I hereby make application for a fellowship to participate in the BEGINNING TOGETHER Institute sponsored by the California Department of Education, Child Development Division (CDD), and WestEd, Center for Child and Family Studies. I certify that all statements made in this application are true and complete. I agree to complete the BEGINNING TOGETHER Institute certification requirements within six (6) months of completion of the Institute. I also agree to incorporate at least ten (10) hours of information on infants and toddlers with disabilities in my infant/toddler training during the two (2) years following completion of this Institute. I agree to respond to annual survey requests from WestEd/CDD to provide information about the infant/toddler trainings that I have provided.
Section III: Director Agreement (if applicable)
I understand that my employee has applied to participate in the BEGINNING TOGETHER Institute. I further understand that her/his participation will require her/his attendance at a four (4) day Institute and that she/he will be required to write a training plan. I also understand that upon completion of the Institute and certification, she/he is required to incorporate ten (10) hours of information on infants and toddlers with disabilities in their infant/toddler training during the two (2) years following completion of this Institute. I will support my employee in this endeavor, and provide the time needed to complete the certification requirements.
Agency Director's Name
Agency Director's Title
Organization/Agency Name
