This project is funded by the Center of Excellence for Learning Science at Tennessee State University through a

contract with the Tennessee Department of Human Services

FORM/ITEM NOTES

1. Application for Academic Financial

Support

Complete and submit one form for each class you’re

registered for.

Please leave no blanks and proofread for accuracy

2. Student Information Form Please complete thoroughly

Proofread for accuracy

3. Request to Share Information This form allows the school to share grades, fee payment

information, etc… as needed by TECTA to provide tuition

assistance.

4. Orientation Certificate OR Transcripts NEW CDA Students – Certificate

Continuing Students - Transcripts

5. Student Detailed Schedule Contact the TECTA office if you aren’t sure which courses to

register for.

6. Account Detail (Statement of Fees) Optional: You may pay your student portion online at this

time

7. Proof of Employment See notes regarding appropriate documentation

8. Student Portion of Tuition Continuing Students: Do not fax or email with tuition

assistance packet. Bring in person on voucher pick-up day.

TUITION ASSISTANCE

PACKET

Use this form to ensure you have all the necessary

documents ready to apply for Tuition Assistance.

Refer to the Tuition Assistance Packet for specific

information about required documentation.

NEW CDA STUDENTS (First Semester Only) – Bring your completed packet to voucher days.

ALL OTHER STUDENTS: Fax or email (recommended) by deadline. NOTE: Watch for a

confirmation by email stating we have received your documentation. It is your responsibility to contact

the TECTA office if you do not receive confirmation within two (2) business days of submitting.

Fax: 931-221-6453 | Email: tecta@apsu.edu

Student’s Name:

___________________

A#: ________________

The TECTA program is funded through a contract with the Tennessee Department of Human Services and Tennessee State University,

Center of Excellence for Learning Sciences.

Revised 2/2017

Center of Excellence for Learning Sciences w Tennessee State University

TECTA Application for Academic Financial Support

Course Information College/University __________________________________ Semester ________ Year______________ Textbook Only_____ Course Name ______________________________________ Subject ________Course Number ________ Section _________ Personal Information Name: Last ___________________________________ First __________________________ Middle ___________________ Social Security Number _____-_____-______ Gender: � Male � Female Citizenship: � United States � Other E-mail ________________________________________________________ Date of Birth _____/_____/_______ Ethnicity: � Hispanic � Non -Hispanic Race: � Asian Pacific Islander � Black � Native American Indian/Alaska Native � Other � Two or more races � White Home Address ______________________________________________________________________________________ City ______________________________________________________ State ________ Zip ___________ Home County ________________________________ Home Phone (___)____________ Mobile Phone (___)____________ Emergency Contact Person _________________________________Phone (___)____________

Academic degree program this semester: � CDA Prep � CDA Renewal � Technical Certificate

� Administrator Credential � Associate Degree � Bachelors Degree � Graduate Degree

Desired Major: � Early Childhood Education � Elementary Education � Pre-K � Other________________

Graduation Status: I will graduate this semester: � Yes � No

Employment Information Your Place of Employment ______________________________________ County where you Work ____________________ Work Address _________________________________________________________________________________________ City _______________________________________________ State _______ Zip ___________ Name of Director: Last ________________________________ First _____________________________ Phone (___)____________Fax (___)____________ Director’s E-mail _____________________________________________

Agency Type � Center � Dept. of Education � Home Visitor � Family � Group Home � High School � Higher Education � Registered � Unregulated Eligibility I understand that I am enrolling in an academic course and will be responsible for completing the class. Failure to complete all information on this form will result in my application not being processed. If for any reason I cannot finish the course, I will submit notice to the TECTA office in writing immediately, return textbook(s), and agree to pay the entire tuition fee for re-enrollment in a TECTA class.

In order to qualify for continued TECTA support, each student must provide a transcript showing that they completed and passed the previous course(s) for which they received financial support from the TECTA program. By signing below I give permission to the institution to release my academic progress and records to representatives from the Tennessee Early Childhood Training Alliance.

Signature __________________________________________________________ Date ______________________

Phone : (931) 221-7585Austin Peay State UniversityPO Box 4514Clarksville, TN 37044

The TECTA program is funded through a contract with the Tennessee Department of Human Services and Tennessee State University,

Center of Excellence for Learning Sciences.

Revised 2/2017

Center of Excellence for Learning Sciences w Tennessee State University

TECTA Application for Academic Financial Support

Course Information College/University __________________________________ Semester ________ Year______________ Textbook Only_____ Course Name ______________________________________ Subject ________Course Number ________ Section _________ Personal Information Name: Last ___________________________________ First __________________________ Middle ___________________ Social Security Number _____-_____-______ Gender: � Male � Female Citizenship: � United States � Other E-mail ________________________________________________________ Date of Birth _____/_____/_______ Ethnicity: � Hispanic � Non -Hispanic Race: � Asian Pacific Islander � Black � Native American Indian/Alaska Native � Other � Two or more races � White Home Address ______________________________________________________________________________________ City ______________________________________________________ State ________ Zip ___________ Home County ________________________________ Home Phone (___)____________ Mobile Phone (___)____________ Emergency Contact Person _________________________________Phone (___)____________

Academic degree program this semester: � CDA Prep � CDA Renewal � Technical Certificate

� Administrator Credential � Associate Degree � Bachelors Degree � Graduate Degree

Desired Major: � Early Childhood Education � Elementary Education � Pre-K � Other________________

Graduation Status: I will graduate this semester: � Yes � No

Employment Information Your Place of Employment ______________________________________ County where you Work ____________________ Work Address _________________________________________________________________________________________ City _______________________________________________ State _______ Zip ___________ Name of Director: Last ________________________________ First _____________________________ Phone (___)____________Fax (___)____________ Director’s E-mail _____________________________________________

Agency Type � Center � Dept. of Education � Home Visitor � Family � Group Home � High School � Higher Education � Registered � Unregulated Eligibility I understand that I am enrolling in an academic course and will be responsible for completing the class. Failure to complete all information on this form will result in my application not being processed. If for any reason I cannot finish the course, I will submit notice to the TECTA office in writing immediately, return textbook(s), and agree to pay the entire tuition fee for re-enrollment in a TECTA class.

In order to qualify for continued TECTA support, each student must provide a transcript showing that they completed and passed the previous course(s) for which they received financial support from the TECTA program. By signing below I give permission to the institution to release my academic progress and records to representatives from the Tennessee Early Childhood Training Alliance.

Signature __________________________________________________________ Date ______________________

Phone : (931) 221-7585Austin Peay State UniversityPO Box 4514Clarksville, TN 37044

The TECTA program is funded through a contract with the Tennessee Department of Human Services and Tennessee State University,

Center of Excellence for Learning Sciences.

Revised 4/2017

Center of Excellence for Learning Sciences w Tennessee State University

TECTA Student Information Form

TECTA Orientation Location or Institution Attending ________________________________________________________

Social Security Number _____ - _____ - _______

Name ________________________________ ________________________ _____________________ Last First Middle Employment Status Your Place of Employment _______________________________________________________________________________

Ages of children in classroom (choose one)

o Birth to 8 months o 9 to 17 months o 18 to 36 months o 3 to 5 year olds

o School-Age o Family Childcare

o Mixed-age Group: Infants o Mixed-age Group: Infants and Preschool o Not a Direct Care Provider

TECTA Support Received for: Semester ___________ Year ____________

Salary: Please note: this question is for research purposes ONLY. Individual responses will not be identified or published.

$ ____________ per Hour

Current Position Title: o Asst. Director o Asst. Director/Teacher o Caregiver/Teacher

o DHS Staff o Director o Director/Teacher o Home Visitor

o Home Visitor Supervisor o Other o Owner of Program o Sub/Floater

o Teacher Aide o Authorized o Volunteer

Number of years in current position ________ Number of years in Early Childhood Field _______

Number of years at current place of employment _______ Hours worked per week_____________

Do you have children with diagnosed delays or disabilities in your classroom? o Yes o No

Number of children in your classroom____________

Please complete the reverse side if you are a first-time TECTA-supported student.

The TECTA program is funded through a contract with the Tennessee Department of Human Services and Tennessee State University,

Center of Excellence for Learning Sciences.

Revised 4/2017

Center of Excellence for Learning Sciences w Tennessee State University

TECTA Student Information Form

Complete this side if this is the first time you are receiving TECTA services. Please check the professional organization(s) to which you belong:

o Head Start Association o National Association for the Education of Young Children

o National Black Child Development Institute o National Child Care Association

o National Family Child Care Association o Tennessee Association for the Education of Young Children

o Tennessee Family Child Care Alliance o Tennessee School-Age Care Alliance

Highest education level completed before seeking TECTA support

o Less than 9th grade o 9th – 12th grade (no diploma) o High School Graduate/GED

o Some College o Technical Certificate o Associate of Applied Science

o Associate Degree o Bachelors/Baccalaureate Degree o Masters/Doctorate Degree

College or University of Highest Degree ________________________________________________________

Major: o Early Childhood Education o Elementary Education o Special Education

o Other ____________________ Graduation Date of Highest Degree ______/_________

Parents’ Educational Levels

Mother

o Less than 9th grade o 9th – 12th grade (no diploma) o High School Graduate/GED

o Some College o Technical Certificate o Associate of Applied Science

o Associate Degree o Bachelors/Baccalaureate Degree o Masters/Doctorate Degree

Father

o Less than 9th grade o 9th – 12th grade (no diploma) o High School Graduate/GED

o Some College o Technical Certificate o Associate of Applied Science

o Associate Degree o Bachelors/Baccalaureate Degree o Masters/Doctorate Degree

Professional Objectives

Why do you want to participate in TECTA training? (Check all that apply):

o Further my education o Help with my job search o Improve my job skills o Obtain a CDA

o Obtain a raise/higher pay

Have you completed other early childhood training during the last 12 months? o Yes o No

Did your employer require the training? o Yes o No

Do you plan to continue working in child care? o Yes o No

If no, please tell us why_________________________________________________________________________________

NOTICE: If you have changed your name and/or address since you last enrolled in a TECTA-supported course, please fill out a TECTA Student Change of Information Form and return it as soon as possible to your local TECTA site.

Records Office Nashville State Community College 120 White Bridge Road

Student Services Building Suite 207

Nashville, TN 37209

615-353-3218

Fax: 615-353-3302

Request to Share Information forms must be accompanied by a valid photo ID if mailing or faxing the

form. Students submitting the form in person must be prepared to show a valid photo ID.

Our office will require that the student be the one to submit the form.

Student’s Name _________________________________________ Student ID: _____________________________________________ I know that the Family Educational Rights and Privacy Act of 1974, as amended (FERPA), protects the privacy of my student educational records and limits access to the information contained in those records. I have indicated below the individual(s) who may have information from my educational records.

1. Name/s_____________________________________________________ Relationship to Student _____________________________________ Address_____________________________________________________ _____________________________________________________________ Phone ______________________________________________________

If they ask, I approve the above named individual(s) to be informed about (initial all that apply).

______________ my grades ______________ my academic standing ______________ my major ______________ my graduation status ______________ my enrollment

Student Signature___________________________________________ Date___________________________

Processed by________________________________________________ Date___________________________ Student ID viewed by _______________________________________ Date___________________________

NSCC 08-17. NSCC is a TBR institution, AA/EEO employer, and does not discriminate against students, employees, or applicants for admission or employment on the basis of race, color, religion, creed, national origin, sex, sexual orientation, gender identity/expression, disability, age,

status as a protected veteran, genetic information, or any other legally protected class with respect to all employment, programs and

activities sponsored by NSCC. Inquiries regarding non-discrimination policies: Director of Human Resources, Human.Resources@nscc.edu,

120 White Bridge Road, 615-353-3305, The Nashville State policy on nondiscrimination can be found at www.nscc.edu/legal/non-

discrimination-policy, Printer: NSCC Copy Center 120 White Bridge Road Nashville TN 37209 Quantity: 19500, © 2016, NSCC.

Noelle Cannon, Director - Tecta at APSUFunding Source

Austin Peay State University - TECTA OfficePO Box 4514 - Clarksville, TN 37044

931-221-7585

ORIENTATION CERTIFICATE OR TRANSCRIPTS

NEW STUDENTS

1. Make a copy of your TECTA Orientation Certificate

2. Add this copy to your Tuition Assistance Packet

3. Store your original certificate in a safe place where you can always find it

RETURNING STUDENTS

1. Log in to your student account (myNSCC) using your A# and PIN

2. Choose the “Student” Tab

3. Select “Student Records”

4. Select “Academic Transcript”

5. Click “Submit”

6. Right click and choose “Print”

7. Add printed Transcripts to your Tuition Assistance Packet

ACCOUNT DETAIL

(STATEMENT OF FEES)

ALL STUDENTS

1. Log in to your student account (myNSCC) using your A# and PIN

2. Choose the “Student” Tab

3. Choose “Student Account”

4. Choose “Account Detail for Term/Confirm Enrollment/Credit Card Payment

5. Select the Current Term

6. **OPTIONAL: If you wish to pay the student portion of your tuition now you

may do so. If not, go to next step.

7. Right Click and Choose “Print”

8. Add printed Account Detail to your Tuition Assistance Packet

STUDENT DETAILED SCHEDULE

ALL STUDENTS

1. Log in to your student account (myNSCC) using your A# and PIN

2. Choose the “Student” Tab

3. Choose “Student Detail Schedule”

4. Right Click and Choose “Print”

5. Add printed Account Detail to your Tuition Assistance Packet

PROOF OF EMPLOYMENT

In Licensed Child Care Program

In Tennessee

All Students

1. Obtain one of the following as proof of employment:

Most Recent Pay Stub

Letter from Employer – Written on Letterhead and Dated within the last 2

weeks

Copy of License (Owners only)

2. Make a copy

3. Add printed copy to your Tuition Assistance Packet

Student Tuition Portion

All Students

Students must show their portion of Tuition to TECTA staff prior to being issued a

voucher. The following are acceptable payment methods:

Personal Check made out to NSCC

Money Order made out to NSCC

If you chose to pay your portion online through myNSCC, your Account

Detail/Statement of fees will reflect this and you do not need further

documentation.

CDA Students: $50 per class

All other students: You will be notified of your portion of the tuition when you

are notified whether or not you received tuition assistance. Please bring this

with you when you pick up your voucher. DO NOT include this in your

faxed/emailed packet.